<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294315
Report Date: 03/05/2024
Date Signed: 03/05/2024 04:04:01 PM


Document Has Been Signed on 03/05/2024 04:04 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:KEENE KARE IIIFACILITY NUMBER:
435294315
ADMINISTRATOR:GAMBOA, ABIGAILFACILITY TYPE:
740
ADDRESS:4629 ROYAL FOREST COURTTELEPHONE:
(408) 616-0615
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 1DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Cristina BanagoTIME COMPLETED:
03:59 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) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Cristina Banago. LPA toured the facility inside and out with ADM. One staff and one resident were observed in the facility. License, personal rights posters, and Administrator Certificate were observed posted at the main entrance.

LPA reviewed one resident file and one staff file.

Living room, family room, kitchen, dinning room and two restrooms were inspected. 4 bedrooms, 1 master bedroom and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet was observed locked. Knives closet, and cleaning product closet were observed unlocked. ADM locked them after LPA's inspection on site. Room temperature was at 68 degree F, and hot water temperature was at 106 degree F in facility. The temperature of the refrigerator was at 33 degree F, and the temperature of the freezer was at 0 degree F.

The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Fire alarm and smoke detectors were tested by ADM. The fire alarm and smoke detectors were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Deficiencies were noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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


Document Has Been Signed on 03/05/2024 04:04 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: KEENE KARE III
FACILITY NUMBER: 435294315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(h)
Maintenance and Operation
(h) Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff. Open-flame lights shall not be used.

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 in that there was no flash lights in the facility during the inspection which poses/posed a potential safety risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
1
2
3
4
Administrator stated to submit a plan of correction by the POC due date to have flash lights in the facility.
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that cabinet of knives and dish watching chemical was observed unlocked which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
1
2
3
4
Administrator stated to submit a plan of correction by the POC due date. Administrator locked the cabinet of knives and dish washing chemical immediately after LPA's inspection.
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) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/05/2024 04:04 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: KEENE KARE III
FACILITY NUMBER: 435294315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that one caregiver did not have a valid first aid certificate during LPA's file review which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
1
2
3
4
Administrator stated to submit a plan of correction by the POC due date to have the staff to receive the first aid training and to obtain the certificate.
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 ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3