435294258-10-29-2024-26-AS-MMOR-DAJ2EF-20241029171952

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294258
Report Date: 10/29/2024
Date Signed: 10/29/2024 05:20:11 PM

Document Has Been Signed on 10/29/2024 05:20 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:	BECK CARE HOME		FACILITY NUMBER:	435294258
ADMINISTRATOR/ DIRECTOR:	ZHANG, YU & LUO, XI-HUA		FACILITY TYPE:	740
ADDRESS:	1681 BECK DRIVE		TELEPHONE:	(408) 866-7858
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95130
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	10/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:25 PM
MET WITH:	Administrator Xi-Hua Luo		TIME VISIT/ INSPECTION COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Xi-Hua Luo. During the visit, LPA observed 6 residents and 2 staff. LPA explained the purpose of the visit. LPA toured the facility inside out which included the Living room, kitchen, dining room, 5 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. LPA's toured the facility garage, which is being used as a storage area / Laundry area. While touring the backyard of the facility LPA's observed a shed. LPA's requested to enter the shed. ADM stated she doesn't have the key and her husband has the key. ADM stated the shed is being used as storage. LPA's looked thru the window and observed that a light was on inside the shed. ADM stated the staff and the residents don't use the storage shed. ADM stated her husband, the owner of the home and co-licensee has the key, because the residents and staff don't use the shed. ADM stated yesterday the gardener was at the home, and stated that is why the light may have been left on. LPA's informed ADM the Department would do a follow up visit to inspect the shed in the backyard. While touring the kitchen of the facility LPA's asked Staff S1 to show where the facility has their knives. S1 pulled opened a drawer in the kitchen, adjacent to the kitchen stove. Inside the drawer was two knives (3:41pm). (Photographs were taken.) ADM stored the knives in a locked cabinet during LPA's visit. LPA observed the medication cabinet had a lock that wasn't engaged, LPA asked Staff S1 to lock it. LPA observed the cabinet below the sink, lock was also not engaged. LPA asked S1 to lock it as well. Page 1 Out of 2.

Romeo Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 10/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

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: BECK CARE HOME	FACILITY NUMBER: 435294258
	VISIT DATE: 10/29/2024

NARRATIVE

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Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 74 degrees F, and hot water temperature was measured at 115 degrees F in both resident bathrooms.

Fire extinguisher was serviced in July 11, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on July 2, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 2 residents.

A deficiency cited during today's visit. This report was reviewed with Administrator Xi-Hua Luo and a copy of the signed report was provided. Appeals rights were also provided

Page 2 Out of 2. END OF REPORT.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 10/29/2024 05:20 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: BECK CARE HOME	FACILITY NUMBER: 435294258
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA's observed in the kitchen, a drawer with two knives, acessible to residents in care. ADM stored the knives in a locked cabinet during LPA's visit. LPA observed the medication cabinet and the cabinet below the sink did not have their lock engaged, LPA asked Staff S1 to lock both of them. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2024
	Plan of Correction
1 2 3 4	ADM secured the knives during visit. ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send to LPA by POC date, October 30, 2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3