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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294191
Report Date: 04/25/2024
Date Signed: 04/25/2024 05:38:07 PM


Document Has Been Signed on 04/25/2024 05:38 PM - 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: 4DATE:
04/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Administrator Anabelle AblanTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to open a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrator Anabelle Ablan.

While investigating the complaint, 26-AS-20240416133846, ADM stated resident R1 had a fall on March 26, 2024, R1 had sustained a fall, which required stitches.

Based on a review of R1's after visit Summary, dated March 26, 2024, R1 was seen for wound care-closed with stitches.

Based on facility file review, the facility did not send an incident report for this fall.

A deficiency is 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: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/25/2024 05:38 PM - 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: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident..., or unexplained absence of any resident.

This requirement was not met as evidenced by;
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ADM stated she will send a written plan of action on how she will ensure any incident which threatens the welfare, safety or health of any resident is reported to CCL. ADM stated she will send the plan of action by POC date, May 2, 2024.
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Based on interview and records reviewed, R1 had sustained a fall in March 26, 2024. ADM stated she did not send an incident report for this fall. This poses/posed a potential health, safety or personal rights risk to persons in care.
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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: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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