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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294206
Report Date: 08/07/2024
Date Signed: 08/07/2024 03:24:36 PM


Document Has Been Signed on 08/07/2024 03:24 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: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:
08/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Annabelle EsperanzaTIME COMPLETED:
03:25 PM
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Licensing Program Analysts (LPAs) Christine Dolores, Marcela Yanez, and Kiran Jain arrived unannounced to conduct the facility's annual required - 1 year annual inspection. LPAs met with Administrator, Annabelle Esperanza.

During visit, LPAs toured the facility to include the resident bedrooms, staff bedrooms, bathrooms, kitchen, living room, dining room, and exterior. All fire exits and passageways are clear of obstruction. Fire extinguisher last serviced on 12/01/2023. Facility has a carbon monoxide detector. Facility temperature maintained at 76 degrees Fahrenheit. Bathroom shower supplied with grab bars and non-slid mats. Hygiene products and linens available. Hot water temperature in bathrooms maintained at 106 degrees Fahrenheit. Bedrooms equipped with beds, linens, dressers, night stands and adequate lighting. 1 resident bedroom observed with half bed rails and oxygen. Oxygen in use sign posted on the bedroom door. Facility has at least 2 days of perishables and 7 days worth of non-perishables foods. Chemicals, disinfectants, and medications observed locked. LPAs reviewed 3 resident files. 3 resident files contains an admission agreement, physician's report, appraisal/needs and services plan, consent form, and personal rights. 3 out of 3 residents centrally stored medication and centrally stored medication records observed maintained. The resident who utilizes the oxygen and bed rails has physician's order on file. LPAs reviewed 3 staff files. 3 out of 3 staff contains a health screening, TB result, fingerprint clearance, and 1st aid certification. 3 out of 3 staff are provided annual training. Facility has an emergency disaster plan. Emergency disaster drills are being conducted quarterly.

Documents obtained to include the Administrator Certificate, LIC308, LIC500, Liability insurance, and Emergency disaster plan. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Annabelle Esperanza and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
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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