Community Care Licensing

Document Has Been Signed on 10/25/2023 06:49 PM - It Cannot Be Edited

FACILITY NAME:	ST JOSEPH SENIOR CARE		FACILITY NUMBER:	015601478
ADMINISTRATOR:	ZENAIDA C BAUTISTA		FACILITY TYPE:	740
ADDRESS:	6437 DAPHNE CT		TELEPHONE:	(510) 795-7603
CITY:	NEWARK	STATE: CA	ZIP CODE:	94560
CAPACITY: 6		CENSUS: 3	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Margrethe Bautista		TIME COMPLETED:	07:00 PM

SUPERVISORS NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

FACILITY NAME: ST JOSEPH SENIOR CARE	FACILITY NUMBER: 015601478
	VISIT DATE: 10/25/2023

Link to Parent Document Below:

FACILITY NAME: ST JOSEPH SENIOR CARE	FACILITY NUMBER: 015601478
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Type A

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 not having S2 complete health screening and tb test which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	S2 will get screened for TB and complete health screening. A copy of Lic 503/TB test result will be submitted to CCL by POC date.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

Link to Parent Document Below:

FACILITY NAME: ST JOSEPH SENIOR CARE	FACILITY NUMBER: 015601478
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Type A

Section Cited

CCR

87463(c)

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. 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 not conducting Reappraisal for R2 who is on catheter which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will complete Reappraisal for R2 addressing R2's catheter and submit a copy to CCL.

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 not havong medicines in the kitchen cabinet locked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2023
	Plan of Correction
1 2 3 4	Staff locked medicines during visit. Deficiency is cleared.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

Link to Parent Document Below:

FACILITY NAME: ST JOSEPH SENIOR CARE	FACILITY NUMBER: 015601478
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Type A

Section Cited

HSC

1569.695(a)

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: 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 not having an updated Emergency Disaster Plan which poses an immediate health, safety or personal rights risk to persons in care. Last plan is dated 2011.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	Administrator will submit to CCL updated Emergency Disaster Plan.

Type A

Section Cited

CCR

87705(c)(2)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (2) The Emergency Disaster Plan, as required in Section 87212, addresses the safety of residents with dementia. 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 not having an updated disaster plan that addresses the safety of residents with dementia which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	Administrator will submit an updated Disaster plan to CCL addressing the safety of residents with dementia and submit a copy to CCL.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

Link to Parent Document Below:

FACILITY NAME: ST JOSEPH SENIOR CARE	FACILITY NUMBER: 015601478
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Type B

Section Cited

CCR

87412(c)(2)(D)

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject. 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 not indicating training hours per subject for S1 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	Administrator will indicate training hours completed by S1 and submit proof to CCL.

Type B

Section Cited

CCR

87613(a)(2)

(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. 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 not having staff trained with R2's catheter which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	Administrator will condcut training with staff on R2's catheter and submit proof ot CCL.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

Link to Parent Document Below:

FACILITY NAME: ST JOSEPH SENIOR CARE	FACILITY NUMBER: 015601478
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Type B

Section Cited

CCR

87613(a)(2)(B)

(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (B) Training shall be completed prior to the staff providing services to the resident. 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 not having staff complete training with R2's catheter prior to staff providing service to R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	Administrator will train staff on R2's catheter.

Type B

Section Cited

CCR

87411(c)(1)

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 not having S2 complete first aid training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	S2 will complet first aid training and submit proof to CCL.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

Link to Parent Document Below:

FACILITY NAME: ST JOSEPH SENIOR CARE	FACILITY NUMBER: 015601478
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Type B

Section Cited

HSC

1569.626(a)(1)

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. 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 not having staff complete required dementia training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	Administrator will conduct required training and submit proof to CCL.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

Link to Parent Document Below:

FACILITY NAME: ST JOSEPH SENIOR CARE	FACILITY NUMBER: 015601478
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Type B

Section Cited

HSC

1569.69(b)

(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. 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 not having staff complete required medication training hours which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	Administrator will conduct training and submit proof to CCL.

Type B

Section Cited

CCR

87506(b)(16)

(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. 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 not having the SPV form in the residents' files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	Administrator will contact families to complete SPV and submit completed copy of the form to CCL.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

Link to Parent Document Below:

FACILITY NAME: ST JOSEPH SENIOR CARE	FACILITY NUMBER: 015601478
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Type B

Section Cited

CCR

87555(b)(27)

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. 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 having fruit flies in the kitchen/dining which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	Administrator will clean, declutter and organize kitchen and dining areas and submit photo proof to CCL.

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 not having an updated disaster drill which poses/posed a potential health, safety or personal rights risk to persons in care. Last fire drill was done on April 2023.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	Administrator will conduct drill and submit proof to CCL.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

Link to Parent Document Below:

FACILITY NAME: ST JOSEPH SENIOR CARE	FACILITY NUMBER: 015601478
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Type B

Section Cited

CCR

87616(b)

(b) Written requests shall include, but are not limited to, the following: 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 not having an approved exception for R2's catheter which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	Administrator will submit a request for exception for R2 by POC date.

Type B

Section Cited

CCR

87705(c)(5)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. 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 not having an updated medical assessment for R1 who has dementia which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	Administrator will request an updated medical assessment for R2 and submit a copy ot CCL.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

Link to Parent Document Below:

FACILITY NAME: ST JOSEPH SENIOR CARE	FACILITY NUMBER: 015601478
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Type A

Section Cited

CCR

87705(c)(4)

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 installing a video camera with audio inside R1's room which poses an immediate health, safety or personal rights risk to persons in care. R1 has dementia and is able to use the bathroom independently.
	POC Due Date: 10/26/2023
	Plan of Correction
1 2 3 4	Administrator will remove camera and will update R1's needs and services to address R1's safety. Administrator will send certifcate of removal of camera by 10/26 and submit updated needs and services plan by 10/31/2023.

Section Cited

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

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023