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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294212
Report Date: 09/18/2024
Date Signed: 09/18/2024 06:06:45 PM

Document Has Been Signed on 09/18/2024 06:06 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:PERPETUAL HELP CARE HOMEFACILITY NUMBER:
435294212
ADMINISTRATOR/
DIRECTOR:		CARUZ, VIRGILIO O.FACILITY TYPE:
740
ADDRESS:1888 ARROYO DE PLATINATELEPHONE:
(408) 258-1434
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 6CENSUS: 5DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:51 PM
MET WITH:Lucena CaruzTIME VISIT/
INSPECTION COMPLETED:
06:05 PM
NARRATIVE
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On 09/18/2024, Licensing Program Analysts Marcela Yanez and Maria (Mita) Partoza (LPAs) conducted an unannounced annual 1 year required inspection. LPA met with Licensee and Administrator Lucena Caruz and stated the purpose of the visit. Facility is licensed for age range 60 and over. All residents maybe non-ambulatory

At 2:55 p.m. LPAs toured the facility inside and outside. including but not limited to the living room, dining room, 4 of 4 resident's bedroom, 2 bathroom and kitchen, kitchen water temperature measured at 106.4 and garage.

LPA observed 4 out of 4 residents rooms to be equipped with hospital beds with half bed rails that were provided by the hospital and skilled nursing facility (SNF), the bedroom has sufficient storage for resident's belonging.

LPAs observed window screens of residents bedroom to be with cob webs. LPAs observed the sliding door in bedroom #3 is missing a screen door.

LPAs observed rotten fruits in the backyard that had fallen from the trees. Paint cans were observed in the backyard. Administrator stated had been there for five years, Administrator stated it is going to be discarded at a future date.

page 1 of 2 see LIC 809-c
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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 3
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: PERPETUAL HELP CARE HOME
FACILITY NUMBER: 435294212
VISIT DATE: 09/18/2024
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Page 2 of 2 cont'd from LIC 809

At 3:10 p.m. LPAs toured the garage and observed Car wash shampoo and car oil.
At 3:15 p,m. LPAs toured the kitchen where Comet was found under the kitchen sink
Refrigerator was observed to have Pepto Bismal that expired on 03/2022.

Medication was also found in the garage which Administrator stated belonged to Staff.
At 3:20 LPAs toured the bathroom where water temperature read 109.9 items found lysol can.
At 3:30 LPAs toured the backyard and observed a bottle of Chlorine bleach, pottting soil, Kitchen pans with oil.


LPA observed a staff (S1) providing care and supervision to 2 residents. S1 is not associated to the facility, however S1 has a fingerprint and criminal background clearance that has not been transferred to the facility.
S1 stated that he/she is on call or as needed and have started to come to the facility the past two weeks (Sept 4, 2024). ADM stated that S1 is not associated and "is not yet an employee of the facility and is not associated to the facility

Deficiencies cited today per California Code of regulation per Title 22 87355 (c)(1).

Due to time constraint, LPAs informed licensee annual inspection will continue and citations will be issued at a later date.


End of Report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/18/2024 06:06 PM - It Cannot Be Edited


Created By: Marcela Yanez On 09/18/2024 at 05:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PERPETUAL HELP CARE HOME
FACILITY NUMBER: 435294212

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2024
Section Cited
CCR
87355(c)(1)

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87355 Criminal record clearance (c) A licensee...may request to tranfer record clearance for one state licensed facilty to another..(1) A signed Criminal Background Clearance... LIC 9182

This requirement not met as evidenced by:
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Licensee stated he/she will submit LIC 9182 to Licensing to transfer Criminal Record Clearance for S1 by the POC due date.
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Based on observation and interview LIC/ADM did not transfer the criminal background clearance of S1. S1 stated that he/she was providing care and supervision since 9/4/2024. *
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 * continued
During the visit LPAs observed S1 providing care and supervision to 2 of 5 residents. Which pose/poses a potential health and 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 Manzano
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024


LIC809 (FAS) - (06/04)
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