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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202876
Report Date: 01/30/2024
Date Signed: 01/30/2024 11:44:56 AM

Document Has Been Signed on 01/30/2024 11:44 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:FAMILY SENIOR CARE HOME IFACILITY NUMBER:
435202876
ADMINISTRATOR:BAUTISTA, ELIZABETHFACILITY TYPE:
740
ADDRESS:2898 GLEN FROST COURTTELEPHONE:
(408) 802-7727
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 4DATE:
01/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Administrator, Elizabeth BautistaTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct a continuation of the annual inspection from 1/27/2024. LPA Rai met with Administrator (ADM) Elizabeth Bautista and stated the purpose of today's visit. LPA Rai observed 2 staff, including ADM and 4 residents at the facility.

On 1/27/2024, LPA Rai reviewed resident (R1)'s Centrally Stored Medication log and R1's medications. LPA Rai observed discrepancy in R1's medication administration record (MAR) for January 2024. 2 Of 13 medications were not administered to R1 as per physician's orders. LPA Rai and S1 counted medication #5 and 2 tablets were not administered to R1. LPA Rai and S1 counted medication #6 and 0.5 tablet was not administered to R1. Based on R1's MAR, R1 did not refuse medication and R1 was not admitted to the hospital after the medication bottles were opened.

During visit, LPA Rai reviewed facility records for 2 staff and 2 residents. During review of 2 of 2 resident files (R1-R2), files did not contain weight log observing resident's weight. ADM stated the facilty is not monitoring resident's weight. Based on record review, R1 has been admitted to the facility for 6 months and did not have any recorded weight log. ADM understood if the resident was not able to use weight machine to record weight, ADM can measure resident's arm and note under observation.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs.
Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. Technical Violation was given. This report was reviewed with Administrator (ADM) Elizabeth Bautista. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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 2
Document Has Been Signed on 01/30/2024 11:44 AM - It Cannot Be Edited


Created By: Simranjit Rai On 01/30/2024 at 11:03 AM
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: FAMILY SENIOR CARE HOME I
FACILITY NUMBER: 435202876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2024
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement is not met as evidenced by:
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Administrator stated to submit a written plan on understanding regulations and schedule in-service training to staff by POC due date. Administrator agreed and understood.
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Based on record review, interview and observation R1's 2 out of 13 meds not administered to R1 as prescribed by the R1's physician which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
01/31/2024
Section Cited
CCR87207

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87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement is not met as evidenced by:
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Administrator stated to submit a written plan on understanding regulations and schedule in-service training to staff by POC due date. Administrator agreed and understood.
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Based on record review, interview and observation, R1's MARs noted medications were given to R1 but medication was not administered based on medications counted in bottle which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
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