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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202674
Report Date: 02/09/2024
Date Signed: 02/09/2024 03:34:54 PM

Document Has Been Signed on 02/09/2024 03:34 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:ROSE GUEST HOMEFACILITY NUMBER:
435202674
ADMINISTRATOR:SACUN, LILIANFACILITY TYPE:
740
ADDRESS:1820 BETHANY AVETELEPHONE:
(408) 649-6532
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 5DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Administrator Lilian SacunTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Lilian Sacun. During the visit, LPA observed 4 residents and 2 staff.

LPA toured the facility inside out with Staff S3, which included the Living room, kitchen, dining room, 2 restrooms and 4 residents 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.

While touring facility bedrooms, LPA observed bedroom #3 at approximately 1pm. S3 stated bedroom #3 is a staff bedroom. LPA observed the door to bedroom #3 does not have a lock. LPA observed a medication container on the dresser. (Photographs were taken.)

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 110 degrees F in both resident bathrooms.

Fire extinguisher was serviced in August 16, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on February 3,2024.

LPA reviewed facility records for 3 staff . While reviewing S3's file, LPA asked ADM for S3's training for 2023. ADM stated she did train S3 but she did not document any of S3's training's for 2023.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: ROSE GUEST HOME
FACILITY NUMBER: 435202674
VISIT DATE: 02/09/2024
NARRATIVE
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LPA reviewed facility records for 3 residents. While reviewing resident records, LPA requested to review facility weight records for R1-R3. ADM stated the facility does not have weight records for the residents. LPA reviewed R1's records; R1's physicians report, dated March 4, 2022, states R1 has dementia. LPA asked ADM if she has a current copy of R1's physicians report, ADM stated that was the latest copy. LPA reviewed R1's Needs and Services Plan, dated March 1, 2023, which was not signed by R1's Responsible party. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff (S1 to S2) and 2 residents (R1-R2).

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Lilian Sacun and a copy of the signed report was provided. Appeal Rights were provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/09/2024 03:34 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/09/2024 at 03:07 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: ROSE GUEST HOME
FACILITY NUMBER: 435202674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. Based on record review 3 Out of 3 resident records reviewed did not have a weight record. ADM stated she did not have a weight record for R1-R3. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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ADM stated she will send a plan of action on how the facility will track the residents change in weight. ADM stated she will send LPA Plan of action, by POC date, 02/16/2024.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record Review and interview, the licensee did not comply with the section cited above. LPA asked ADM to review S3's training documentation. ADM stated she did not have documentation of S3's training for the year 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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ADM stated she will send a plan of action on how the facility will ensure staff are trained 20 hours annually, eight hours of which shall be dementia care training and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care. ADM stated she will send documentation S3 has been trained to LPA. ADM stated she will send the plan by POC date, 02/16/2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/09/2024 03:34 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/09/2024 at 03:07 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: ROSE GUEST HOME
FACILITY NUMBER: 435202674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(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
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Based on observation and interview, the licensee did not comply with the section cited above. Bedroom #3 is a staff bedroom which does not have a lock. Inside Bedroom #3 are S3's medications, which are accessible to residents in care. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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ADM stated she will send plan of action on how she will ensure staff medications are inaccessible to residents in care. ADM stated she will send plan of action by POC date, 02/16/2024.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(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
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Based on record Review and interview, the licensee did not comply with the section cited above. LPA reviewed R1's records; R1's physicians report, dated March 4, 2022, states R1 has dementia. ADM stated that was the latest copy. LPA reviewed R1's Needs and Services Plan, dated March 1, 2023, which was not signed by R1's Responsible party. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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ADM stated she will send plan of action on how the facility will ensure dementia residents have their annual medical assessment and reappraisal. ADM stated she will send plan of action by POC date, 02/16/2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
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