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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294212
Report Date: 09/23/2024
Date Signed: 09/23/2024 04:13:23 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/23/2024 04:13 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:
09/23/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Virgilio O Caruz & Lucena CaruzTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza a conducted an unannounced continuation of the required 1 year inspection visit and met with licensee/administrator (LIC/ADM) Virgilio O. Caruz and Lucena Caruz and stated the purpose of the visit.

The facility is licensed to serve adults 60 and over and all may be non-ambulatory. LPA observed 5 out of 5 residents are present at the facility that have neurocognitive impairment, 2 out of 5 are ambulatory and 3 out 5 are non ambulatory and 3 out 3 staff were present.

On 9/18/2024 at 2:45 pm LPAs Marcela Yanez and Maria (Mita) Partoza, toured the facility inside and outside with ADM including but not limited to the kitchen, bathroom, dining room, living room, 4 out of 4 residents rooms, garage, backyard and exterior walkways. The temperature inside the home was at 73 degrees Fahrenheit.

The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. Under the sink cabinet is used to store kitchen utensils. LPA observed a Comet Bleach powder cleaner under the sink, the cabinet is not locked and is accessible to residents in care. Inside the refrigerator, LPA observed a bottle of Pepto-Bismol that expired on 3/2022 that was accessible to residents.

LPA observed 2 bathroom (B1 and B2) one in the hallway and one by the dining room. The facility has a second floor and stairs was gated and no resident is allowed in the 2nd floor due to mobility. LPA observed hard water residue on the shower head of B1. LIC/ADM stated the shower area of B1 is not used by the resident because of the step up that is approximately more than 1/2 foot high. B2 is used by the resident for showering instead. LIC/ADM stated that B1 is used by residents for toileting needs.

Page 1 of 2, see LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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 8
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: 09/23/2024
NARRATIVE
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LPA observed that medications are kept locked and inaccessible to residents. The first aid kit is complete and is accessible to staff. However, staff medication observed in the garage are not locked. Licensee stated the prescription medication belongs to S2 and stated that the garage is off limits to the residents due to their neurocognitive impairment and a staff is always present during the day and the door is locked during the night.

During the tour, LPAs observed a gallon container of Ultra Bleach at the right side of the entry way of room 3, and contained liquid bleach that is approximately 6 to 8 ounces full. LPA opened the bottle and was able to determine by smell that the liquid inside the container is bleach.

LPAs continued to inspect the backyard and observed a large bag of Miracle Gro that is opened. LIC/ADM stated that the Miracle Gro is used to re-pot the tomato plants. LPA observed hanging clothes on the clothesline and LIC/ADM proceeded to take them off the clothesline during inspection. The backyard has a shed that is locked, covered gas stove top, a bag of charcoal in front of the shed and other items that were covered with a tarp. 2 propane gas tank that was hidden by a plank of wood. LIC/ADM stated that the outdoor gas stove is used to cook fish. LPA noticed a cast iron pan with oil placed in the open on top of a table.

The backyard walkway leads to the side walkway of the facility. LPA observed cans of paint approximately 6-8 cans that ware rusted on the right side of the walkway leading toward the gate and is accessible to residents in care. LIC/ADM stated the cans of paint have been sitting there for more than 5 years and stated that they were having a hard time finding someone to pick up the paint. LIC/ADM stated the paint cans are scheduled to be removed on 10/3/2024.

LPAs inspected the exterior of the facility and found cobwebs on the bathroom window had accumulated dust that was not removed or wiped clean. LPAs walked towards the wood gate and LIC/ADM stated the gate needs to be pulled up to open smoothly and not scrape the pavement. The fence gate is wider to accommodate non-ambulatory residents.

page 2 of 4, SEE LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
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: 09/23/2024
NARRATIVE
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LPAs continued to inspect the facility's interior, and while inspecting, LPA Partoza observed a carbon monoxide alarm near the bathroom. LPAs inspected the bathroom, observed 3 out of 4 light bulbs by the mirror was burned out and has cobwebs. The hallways light sconces has cobwebs. LPA observed that couches in the living room are covered with a blanket. The darker couch has unknown stains / residue on arm. Behind the front door leaning by the wall is removable 6 foot foldable wall divider/panel.

LPAs observed that all residents bed have 1/2 bed rail that were ordered by the therapist and are used for resident's mobility to help the resident get in an out of the bed.

The facility is equipped with a fire, smoke and carbon monoxide alert system that is in good working condition, night lights on the hallway are in good working condition. The hallway and walkways are free from obstruction.

On 9/23/2024, LPA Partoza, continued the inspection and reviewed the facility file, resident file and staff file.
During today's visit LPA did not observed S1, at the facility. LIC/ADM stated, S1s criminal background and fingerprint clearance has been submitted on 9/20/2024.

LPA reviewed the facility file and the last fire and earthquake drill was conducted in September of 2023.

LPA reviewed 5 out of 5 resident records such as but not limited to the centrally stored medication and destruction record (CSMDR), admission agreement, needs and services plan, health screening and observed the following R1 to R5 are missing the Emergency information form, R2 to R5 is missing the consent form, R3 is missing the appraisal needs and services plan, R2 and R3 are missing personal rights. 5 out of 5 have the Centrally Stored Medication and Destruction Record.


page 3 of 4, LIC 809c
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8
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: 09/23/2024
NARRATIVE
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LPA reviewed 4 out of 4 staff records and observed that required training, first aid/CPR training, background clearance were updated. However, other documents required was not available for LPA to inspect at the time of inspection. LIC/ADM stated it was misfiled and will need time to organize the file for each staff.

Deficiencies will be cited during today's visit based on California Code of Regulation Title 22, 87555 (24), 87705(f)(2), 87705 (k)(3), 87506 (a), 87412(a), 8742(f), 87303(a).

An exit interview was conducted with licensee/administrator Lucena Caruz. A copy of the report and appeals rights were provided.

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End of Report

*Due to technical difficulty the report was sent by email to licensee.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 09/23/2024 04:13 PM - It Cannot Be Edited


Created By: Maria Partoza On 09/23/2024 at 02:18 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: 09/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2024
Section Cited
CCR
87555(24)

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87555 General Food Service Requirements
(24) Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored. This requirement is not met as evidenced by
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LIC stated the under the sink cabinet will only be used for kitchen equipment and no cleaning detergent will be stored in the same place as kitchen equipment. LIC/ADM removed the detergent during the time of inspection
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Based on observation, licensee did not store toxic substance (Comet Powder Cleaner) in a separate area not used for kitchen equipment, which pose/poses an immediate health and personal right risk to persons in care.
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Type A
09/24/2024
Section Cited
CCR87705(f)(2)

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87705 Care of Persons with Dementia (f)... the following shall be stored inaccessible to residents with dementia (2)Over-the-counter medication...supplements or vitamins...and toxic substances such as… gardening supplies, cleaning supplies and disinfectants.
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LIC/ADM stated that the vitamins and supplement of staff was kept, Miracle Gro, Liquid bleach and charcoal are now in a locked storage.
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This requirement is not met as evidenced by:
Based on observation, LIC/ADM did not store staff medications & vitamins, Miracle Gro, Liquid bleach and paints in a locked cabinet not accessible to residents in care. 3 out of 5 residents have dementia. 2 out of 5 are ambulatory.
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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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 09/23/2024 04:13 PM - It Cannot Be Edited


Created By: Maria Partoza On 09/23/2024 at 02:31 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: 09/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2024
Section Cited
CCR
87705(k)

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87705 Care of Persons with Dementia (k)... continuing requirements must be met...(3) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement is not met as evidenced by:
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LIC/ADM stated that a fire & drill training will be conducted with staff and resident and will submit proof of training by the POC due date.
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Based on record review & interview, LIC/ADM did not maintain continuing requiremet and have not conducted fire & earthquake drill training. LIC/ADM stated the last training was done in 2023, which pose/poses an immediate, health, safety & personal risks to persons in care.
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Type B
10/04/2024
Section Cited
CCR87506(a)

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility … This requirement is not met as evidenced by:
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LIC/ADM stated that all forms required for resident record will be completed by the plan of correction due date.
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Based on record review, LIC/ADM did not ensure residents have complete and current record for each resident in the facility. 4 out of 5 does not have consent form, 5 out of 5 does not have a complete Emergency ID information, 1 out of 5 does not have appraisal needs & services plan. *cont
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*cont. Which pose/poses a potential health, safety & personal rights risk to persons in care.
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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 09/23/2024 04:13 PM - It Cannot Be Edited


Created By: Maria Partoza On 09/23/2024 at 02:50 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: 09/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
87412(a)

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87412 Personnel Records (a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by:
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LIC/ADM stated that the record of employees were misfiled and is in the process of organizing and separating each record of the staff. LIC/ADM stated that she will submit proof of correction by the POC due date.
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Based on record review & LIC/ADM did not ensure that personnel records are maintained. LPA reviewed 4 out 4 staff record and did not find health screening, SOC341A, LIC 501, TB test. Which pose/poses a potential health, safety & 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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 09/23/2024 04:13 PM - It Cannot Be Edited


Created By: Maria Partoza On 09/23/2024 at 02:59 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: 09/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2024
Section Cited
CCR
87303(a)(c)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. ...for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by:
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LIC/ADM stated that the all bulbs and windows will be cleaned and facility will be kept in good repair. LIC/ADM stated plan of correction will be submitted by the due date.
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Based on observation, LIC/ADM did not keep the facility clean, safe & sanitary. LPA observed burned light bulbs in bathroom 2 near the dining room, cobwebs were observed on the light sconces by the hallway, unknown residue on the couch arm, and exterior bathroom - *cont
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*cont. bathroom screen was covered with dust which pose/poses an immediate health, safety & personal right 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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024


LIC809 (FAS) - (06/04)
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