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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440703228
Report Date: 08/27/2024
Date Signed: 08/27/2024 04:00:17 PM

Document Has Been Signed on 08/27/2024 04:00 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:HANOVER GUEST HOMEFACILITY NUMBER:
440703228
ADMINISTRATOR/
DIRECTOR:		MARSHA BELLEZAFACILITY TYPE:
740
ADDRESS:813 HANOVER STREETTELEPHONE:
(831) 426-0618
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 15CENSUS: 10DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator, Stephanie MeansTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Marcella Tarin and Christine Dolores conducted a required unannounced 1 year visit and met with Administrator Stephanie Means. During the visit LPAs toured the facility inside and out.

LPAs toured the kitchen area. LPAs observed a perishable food supply of at least 2 days and a nonperishable food supply of 7 days. LPAs observed the kitchen is supervised by staff which contains sharp objects, chemical disinfectants,and medications. Refrigerator temperatures maintained between 42 and 52 degrees F. Administrator was advised. Freezer temperature maintained at 0 degrees F.

LPAs toured 10 resident rooms. LPAs recorded bathroom water temperature 108 degrees Fahrenheit in all 3 resident bathrooms. Hot water temperature next to room #1 maintained at 108 degrees F. The bathroom had functioning lights and available soap and paper towels. LPAs toured the bathrooms in each bedroom and found them to have working lights, available soap and paper towels. LPAs toured 10 resident bedrooms. Each room had working lights, and available bedding and clothing storage areas. LPAs observed 2 resident (Room 4 and Room 7) sliding door exits contained a pole and wooden plank that obstructed the opening of the sliding door. LPAs observed hygiene items on a dresser in Room 1. Based on record review, the Dementia resident is at risk if allowed access to hygiene items. LPAs tested the carbon monoxide detector to be functioning properly. The fire extinguisher last serviced on 1/5/2024.

LPAs reviewed 5 resident files. It was observed that 5 residents Appraisal Needs and Services Plan were updated but did not contain signatures from the resident and responsible parties. LPAs observed that 5 Centrally Stored Medication and Destruction Record (CSMDR) were not maintained as multiple resident’s medications were not part of the CSMDR and did not contain a start date. 1 resident file did not contain a Physician’s Report. 2 residents did not contain an order for half-bed rails. See LIC809C.
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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 7
Document Has Been Signed on 09/10/2024 10:45 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/28/2024 02:46 PM


Created By: Marcella Tarin On 08/27/2024 at 01:58 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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This is an amended report for visit date 8/27/2024
Based on observation, interview and record review, the licensee did not ensure at least 1 staff on duty and on the premises has CPR and First Aid training. LPAs observed 2 staff scheduled on shift during visit that did not have CPR and First Aid certification which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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Licensee states to work on getting all staff CPR and First Aid certified. Licensee will submit a written plan to ensure staff receive certification to LPA Tarin via email by POC due date.
Type A
Section Cited
CCR
87705(g)
(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items.
This requirement is not met as evidenced by:
Deficient Practice Statement
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This is an amended report for visit date 8/27/2024.
Based on observation, interview and record review, the licensee did not ensure hygiene items were inaccessible to a Dementia resident who is at risk if allowed access to hygiene items based on physcian's report. LPAs observed mouthwash, shampoo, conditioner, and toothpaste on a dresser in Dementia resident's room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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Licensee will submit a written plan to ensure that hygiene items are inaccessible to Dementia residents who are at risk if allowed access to hygiene items to LPA Tarin via email by POC due date.
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:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 09/10/2024 10:46 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/28/2024 04:41 PM


Created By: Marcella Tarin On 08/27/2024 at 01:58 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(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
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This is an amended report for visit date 8/27/2024.
Based on observation, interview, and record review, the licensee did not ensure 5 resident's appraisal/needs and services plan was reviewed and signed by the resident and/or resident's representative which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
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Licensee will submit a written plan to residents appraisal needs and service plans are reviewed and signed by resident and/or residents representative via email to LPA Tarin by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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
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This is an amended report for visit date 8/27/2024.
Based on observation, interview and record review, the licensee did not ensure drills were conducted quartely which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
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Licensee will submit a written plan to ensure drills are conducted and documented quartely via email to LPA Tarin by POC due date.
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:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
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: HANOVER GUEST HOME
FACILITY NUMBER: 440703228
VISIT DATE: 08/27/2024
NARRATIVE
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LPAs reviewed 5 staff files. It was observed that 5 staff files did not contain 10 hours of initial and/or 20 hours of annual training on topics covered in Section 87707. 5 out of 5 staff do not have CPR and First Aid certification. LPAs observed 2 staff scheduled during visit did not have CPR and First Aid certification. 5 out of 5 staff obtains fingerprint clearance.

Facility has emergency disaster plan. LPAs advised to update the emergency disaster plan. Facility is not conducting emergency drills quarterly. LPAs observed flashlights in resident bedrooms.

Facility does not have a written Infection Control Plan. Administrator was advised.

Posters observed to include personal rights, ombudsman, facility license. LPAs did not observe the licensing complaint poster.

Documents were requested by 8/30/2024 to include Infection Control Plan, updated Emergency Disaster Plan, Liability Insurance, Administrator Certificates.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809Ds. This report was reviewed with Administrator Stephanie Means and a copy of the report and Appeal Rights were provided

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 09/10/2024 10:46 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/28/2024 03:00 PM


Created By: Marcella Tarin On 08/27/2024 at 03:10 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
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This is an amended report for visit date 8/27/2024.
Based on observation, interview and record review, the licensee did not ensure that sliding exit doors tracks were free of obstruction. LPAs observed a pole and a wooden plank obstructing the sliding exit door tracks which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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During visit, Licensee removed the objects (a pole and a wooden plank) from the sliding exit doors track. Licensee will submit a written plan to ensure all indoor and outdoor passagways and stairways are free from obstruction via email by POC due date to LPA Tarin.
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:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 09/10/2024 10:47 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/28/2024 03:04 PM


Created By: Marcella Tarin On 08/27/2024 at 03:16 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
This is an amended report 8/27/2024
Based on observation, interview and record review, the licensee did not ensure to provide 5 staff with 10 hours of initial and 20 hours of annual training on topics covered in Section 87707 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
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Licensee will submit a written plan to ensure staff obtain 10 hours of initial training and 20 hours of annual training with topics covered in Section 87707 Section cited to ensure compliance via email to LPA Tarin by POC due date.
Type B
Section Cited
CCR
87608(a)(3)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
Deficient Practice Statement
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This is an amended report for visit date 8/27/2024.
Based on observation, interview, and record review, the licensee did not ensure 2 residents files contained a physician's order for half bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
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Licensee states she will request the physician's orders documenting the order for half bed rails from Hospice to ensure compliance and submit plan to LPA Tarin via email by POC due date.
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:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 09/10/2024 10:47 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/28/2024 03:07 PM


Created By: Marcella Tarin On 08/27/2024 at 03:52 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
This is an amended report for visit date 8/27/2024.
Based on observation, interview, and record review, the licensee did not ensure 5 residents CSMDRs were maintained and 1 resident's file did not contain a physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
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Licensee will submit a written plan to ensure residents Centrally Stored Medication and Destruction Records (CSMDR) are maintained and residents files contain a physician's report via email to LPA Tarin by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
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