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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294191
Report Date: 09/16/2023
Date Signed: 09/16/2023 11:10:54 AM


Document Has Been Signed on 09/16/2023 11:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:KINGDOM HEARTS CARE HOMEFACILITY NUMBER:
435294191
ADMINISTRATOR:ABLAN, ANABELLEFACILITY TYPE:
740
ADDRESS:3664 BRIGADOON WAYTELEPHONE:
(408) 223-3305
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 5DATE:
09/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Administrator Anabelle AblanTIME COMPLETED:
11:20 AM
NARRATIVE
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On 09/16/2023, Licensing Program Analyst (LPA) Manuel Monter arrived at the facility unannounced to conduct an Annual Random Inspection. LPA was greeted by staff Lina Serrano (S1). LPA informed staff the reason of the visit. Administrator (ADM) Anabelle Ablan arrived shortly during the inspection.

The facility was toured inside/out which included; the living room, dining room, kitchen, resident bedrooms, resident bathrooms, staff bedroom, garage and backyard. Walkways and emergency exit passages were free from obstruction.

LPA observed locked cabinets for Medications, Sharps and toxic materials. Two day perishable food supplies and seven day nonperishable food supplies were observed. The linen supplies in the hallway closet was observed. The hot water temperature in both clients bathrooms and hallway bathroom were measured to range from 107 degrees F to 109 degrees F. The room temperature registered at 72 degrees F. Signal alarms were on and operational. Smoke alarms is combined with carbon monoxide was observed, tested and are operational. First aid kit was present and complete. Fire and Earthquake drills are conducted as required. The facility's last drill was conducted on March 30th 2023. ADM stated the facility was due for an a drill. LPA observed fire extinguisher was serviced on May 2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 3 staff (S1 to S3) and 2 residents (R1-R2).

A deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Anabelle Ablan. Appeal rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2023 11:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: KINGDOM HEARTS CARE HOME
FACILITY NUMBER: 435294191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the ADM did not comply with the section cited above. Facility records state the last drill conducted was on 03/30/2023. ADM stated the facility was due for a drill. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2023
Plan of Correction
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ADM stated she will conduct a fire drill by plan of correction date, 09/23/2023. ADM stated she will send documentation to LPA, showing a drill has been conducted. ADM agreed and understood.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2023
LIC809 (FAS) - (06/04)
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