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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294272
Report Date: 03/23/2024
Date Signed: 03/23/2024 12:46:05 PM


Document Has Been Signed on 03/23/2024 12:46 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:CARING HEARTS SENIOR CARE HOME, INCFACILITY NUMBER:
435294272
ADMINISTRATOR:MICHELLE PAGKALINAWANFACILITY TYPE:
740
ADDRESS:3065 VAN SANSUL AVENUETELEPHONE:
(408) 296-7081
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:12CENSUS: 12DATE:
03/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrative Assistant Mila FranciscoTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrative Assistant (AA) Mila Francisco. During the visit, LPA observed 12 residents and 5 staff.

LPA toured the facility inside out with AA which included the Living room, kitchen, dining room, restrooms and 9 resident 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. 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 72 degrees F, and hot water temperature was measured at 115 degrees F in resident bathrooms.

While touring the backyard, LPA observed a container of anti freeze coolant, directly to the left of the storage unit. LPA also observed cans of paint, and a gasoline container, behind the storage unit. (Photographs were taken.) AA stated she will remove toxic materials and put them inside the storage.

Fire extinguisher was serviced in July 11, 2023. The facility was equipped with smoke and carbon monoxide detectors. AA stated the sprinkler system had its annual inspection on January 2024. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on November 16, 2023.
LPA reviewed facility records for 4 staff and 4 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 2 residents.

A deficiency is being cited during today's visit. This report was reviewed with ADM MICHELLE PAGKALINAWAN via phone call and Administrative Assistant Mila Francisco and a copy of the signed report was provided. Appeal rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2024
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 2


Document Has Been Signed on 03/23/2024 12:46 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: CARING HEARTS SENIOR CARE HOME, INC
FACILITY NUMBER: 435294272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observation, the licensee did not comply with the section cited above. LPA observed a container of anti freeze coolant, directly to the left of the storage unit. LPA also observed cans of paint, and a gasoline container, behind the storage unit. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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ADM stated they will store the toxics inside the storage. ADM stated she will send me a written plan of action on how she will ensure disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to residents in care.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2