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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200793
Report Date: 04/03/2024
Date Signed: 04/05/2024 08:19:12 AM

Document Has Been Signed on 04/05/2024 08:19 AM - 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:NIKKO'S RESIDENTIAL CARE HOME IIFACILITY NUMBER:
435200793
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		VILLAREAL, MICHELLEFACILITY TYPE:
735
ADDRESS:5724 BLOSSOM AVETELEPHONE:
(408) 972-1792
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 2DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
03:29 PM
MET WITH:Michelle VillarrealTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 4/3/2024, at 3:20 p.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived at the facility to conduct an unannounced annual required inspection. LPA was greeted by 3 facility staff. LPA spoke to administrator Michelle Villarreal on the phone and ADM stated he/she will be in the facility as soon as possible.

LPA reviewed 2 resident file and 3 staff files. LPA toured the facility inside and outside including the bedrooms, bathrooms, kitchen, and living room area.

Bedrooms were observed with appropriate furniture and in good repair. Bathroom are equipped with grab bars and nonskid floor mats. Facility is equipped with comfortable lighting. Facility temperature was maintained at 70 degrees Fahrenheit. Hot water temperature in the bathroom measured at 140.4 degree F. Kitchen hot water measured at 154.4 degree F. During the visit the water temperature was adjusted by the facility ADM and maintenance person.

Hygiene items, toiletries, and linens were available to the residents. Centrally stored medications, sharp objects, and toxins were locked and inaccessible to the residents.

Kitchen area was observed clean and sanitary 2 days’ worth of perishables and 7 days’ worth of nonperishable were observed.

Facility is equipped with smoke detectors and carbon monoxide detectors. Hallways and passageways were free of obstruction. Facility is equipped with First Aid Kit.

Centrally stored medications were reviewed with medication log and found the log to be in compliance with the regulation.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: NIKKO'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435200793
VISIT DATE: 04/03/2024
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Residents and staff records were reviewed. Facility staff all have criminal record clearance to work at the facility and are associated to the facility. Staff records have the following personnel record, health screening with TB test information, criminal record statement, with current CPR and first aid certificate.

Resident records have the following admission agreement, medical assessment with TB test information, updated needs and services plan, and personal rights.

The following forms to be updated and submitted to CCL 04/15/2024
LIC 500 Personnel Record
Administrator Certificate
LIC 610E Emergency Disaster Plan
Surety Bond
LIC 308

During today's visit a deficiency was cited per California Code of Regulations (CCR) Title 22. An exit interview was conducted with ADM Michelle Villarreal, a signed copy of the report and appeals rights was provided
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/05/2024 08:19 AM - It Cannot Be Edited


Created By: Maria Partoza On 04/03/2024 at 05:33 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: NIKKO'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435200793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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. During inspection LPA measured 2 out of 2 water faucets. Bathroom hot water temperature measured at 140.4 and Kitchen hot water measured at 154.4. ADM did not maintain the regulated water temperature of 105 to 120 degree F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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ADM stated that she/will monitor the water temperature for a week and log the water temperature measured for one week. ADM stated she will plan of correction to LPA by the due date and will monitor and measure water temperature for both places for a week and create a log as proof that the deficiency is corrected.
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 Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


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