435294272-3-26-2025-26-AS-CKAI-DF5VT6-20250326164236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294272
Report Date: 03/26/2025
Date Signed: 03/26/2025 04:42:51 PM

Document Has Been Signed on 03/26/2025 04:42 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, INC		FACILITY NUMBER:	435294272
ADMINISTRATOR/ DIRECTOR:	MICHELLE PAGKALINAWAN		FACILITY TYPE:	740
ADDRESS:	3065 VAN SANSUL AVENUE		TELEPHONE:	(408) 296-7081
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY: 12	TOTAL ENROLLED CHILDREN: 0	CENSUS: 12	DATE:	03/26/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Michelle Pagkalinawan		TIME VISIT/ INSPECTION COMPLETED:	04:50 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) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Administrator (ADM), Michelle Pagkalinawan. During visit, LPA toured the facility with ADM to include all the resident bedrooms, 3 bathrooms, hallways, kitchen, dining room, living room, garage, shed and exterior. The shed contains storage items. The facility currently has 6 out of 6 hospice care residents. 4 facility staff present are fingerprint cleared and associated to the facility. Facility temperature maintained at 75 degrees F. The stairways, ramps, and hand railings observed sturdy and in good repair. Fire exit routes are free and clear of obstruction. LPA observed the exit door next to the laundry machines and front door contains a door alarm that was not functioning. ADM has a plan to replace the batteries for the door alarms. Fire extinguisher last serviced on 09/16/2024. There are 2 operable carbon monoxide detectors in each wing of the facility. Resident bedrooms equipped with beds, linens, dressers, night stands and adequate lighting. Bathrooms equipped with soap, paper supplies, and hand washing signs. The bathtub contains a non-slip mat. The bathroom hot water temperature next to room #5 was initially measured at 133 degrees F and the hot water temperature next to room #7 was measured at 117 degrees F. Both bathrooms share the same hot water furnace. During visit, the ADM turned down the hot water temperature. LPA measured the bathroom hot water temperature next to room #5 and #7 maintained at 117 degrees F. See LIC809C.

Jackie Jin	TELEPHONE: (714) 319-3786
Christine Kabariti	TELEPHONE: (408) 324-2112
	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

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 5

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 5

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
	VISIT DATE: 03/26/2025

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
26
27
28
29
30
31
32

Bathroom hot water temperature next to room #3 uses a separate hot water furnace, which was initially maintained at 114.8 degrees F.

Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. LPA observed the drawer that stores sharp objects was not locked in the kitchen area. Based on observation and interview, the lock for the drawer was broken. LPA also observed the cabinet that stores resident medications was not locked in the kitchen area. Based on observation and interview, the lock for the cabinet was broken. ADM and staff state that they close the kitchen door during the evening, however, the kitchen door does not lock. Staff immediately fixed the locks for the sharp objects and medications. During visit, LPA observed the sharp objects and medications were secured and locked.

Facility has emergency lighting and flashlights. Facility has an emergency disaster plan. Disaster drills are completed quarterly and the last drill completed on 02/2025.

4 resident files were reviewed. 2 out of 4 resident's file did not contain an up-to-date needs and services plan, as they were dated in 2022 and 2023. LPA observed the facility documents the residents change of condition, however, the information was not being transferred onto the needs and services plan. 4 out of 4 resident files were completed to include an admission agreement, physician's report, TB result, consent form, personal rights, and safeguard of personal properties and valuables form. 4 out of 4 residents medications and centrally stored medication records were inspected with all medications accounted for. 4 staff files were reviewed. 4 out of 4 staff files were observed complete to include fingerprint clearance, health screening, TB result, and annual training records.

ADM was reminded to pay their licensing fee that is currently due.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. Advisory note provided. This report was reviewed with Administrator (ADM), Michelle Pagkalinawan and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Kabariti	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 03/26/2025 04:42 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: 03/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above wherein the medication cabinet and drawer that contains sharp objects was not locked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2025
	Plan of Correction
1 2 3 4	Licensee immediately fixed the lock on the medication cabinet and sharp objects drawer. Licensee will submit a statement of understanding of the section cited above to LPA Kabariti via email by POC due date.

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.

Jackie Jin	TELEPHONE: (714) 319-3786
Christine Kabariti	TELEPHONE: (408) 324-2112
	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 03/26/2025 04:42 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: 03/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not comply with the section cited above in wherein 2 out of 4 resident's did not have an up-to-date needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/02/2025
	Plan of Correction
1 2 3 4	Licensee will ensure that all resident's will have an up-to-date needs and services plan, going forward. Licensee will submit the 2 resident's updated needs and services plan and statement of understanding of the section cited to LPA Kabariti via email by POC due date of 04/02/2025.

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.

Jackie Jin	TELEPHONE: (714) 319-3786
Christine Kabariti	TELEPHONE: (408) 324-2112
	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC809 (FAS) - (06/04)

Page: 5 of 5