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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294206
Report Date: 07/26/2024
Date Signed: 07/26/2024 12:48:47 PM


Document Has Been Signed on 07/26/2024 12:48 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
Lookup Error,
, CA



FACILITY NAME:KIMBERLY'S ELDER KARE KOTTAGEFACILITY NUMBER:
435294206
ADMINISTRATOR:KENDALL HALLFACILITY TYPE:
740
ADDRESS:2770 MOORPARK AVENUETELEPHONE:
(408) 483-1029
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:6CENSUS: 4DATE:
07/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Annabelle EsperanzaTIME COMPLETED:
12:45 PM
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On 7/26/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint visit to deliver findings. LPA met with Administrator Annabelle Esperanza and explained the purpose of today's visit.

During the investigation of complaint control #26-AS-20220831120143, LPA Donato found that the facility did not report an incident to Licensing in which a resident was sent to the emergency room due to UTI.

Deficiency of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Co-Administrator and a copy is provided with appeal rights.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
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 07/26/2024 12:48 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
Lookup Error,
, CA


FACILITY NAME: KIMBERLY'S ELDER KARE KOTTAGE
FACILITY NUMBER: 435294206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident...(D)Any incident which threatens the welfare, safety or health of any resident...
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Licensee to submit a plan to address reporting requirement issues in the facility. Licensee to submit plan by POC deadline.
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This was not met as evidenced by:
Based on interviews, Licensee did not report an incident to Licensing which poses an immediate 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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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