Community Care Licensing

Document Has Been Signed on 09/09/2022 02:42 PM - It Cannot Be Edited

FACILITY NAME:	RILLERA'S GUEST HOME 2		FACILITY NUMBER:	445201931
ADMINISTRATOR:	RILLERA, ZOSIMA		FACILITY TYPE:	740
ADDRESS:	115 GERA COURT		TELEPHONE:	(831) 768-1965
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY: 6		CENSUS: 5	DATE:	09/09/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:02 PM
MET WITH:	Elis Pascual		TIME COMPLETED:	02:50 PM

SUPERVISORS NAME: Sarah Yip LICENSING EVALUATOR NAME: David Marrufo LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022

Link to Parent Document Below:

FACILITY NAME: RILLERA'S GUEST HOME 2	FACILITY NUMBER: 445201931
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/16/2022 Section Cited CCR 87211(a)(1)(A)	1 2 3 4 5 6 7	87211(a)(1)(A) Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for	1 2 3 4 5 6 7	Licensee agrees to retrain staff on reporting deaths of residents to the Department, including deaths that occur outside of the facility. The training records must be submitted to CCL by POC date and the records must include names of staff trained, dates of training, and name and qualifications
	8 9 10 11 12 13 14	the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement was not met as evidenced by: Licensee did not report a resident death to licensing that occurred at a hospital sometime between 07/07-10/2022, which poses a potential safety risk to residents in care.	8 9 10 11 12 13 14	of trainer.
Type B 09/16/2022 Section Cited CCR87211(a)(2)	1 2 3 4 5 6 7	87211(a)(2) Reporting Requirements: a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which	1 2 3 4 5 6 7	Licensee agrees to retrain staff on reporting COVID cases and any epidemic outbreak to the Department. The training records must be submitted to CCL by POC date and the records must include names of staff trained, dates of training, and name and qualifications of trainer.
	8 9 10 11 12 13 14	threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by: Licensee did not report COVID cases of 4 residents and 2 staff to CCL, which poses a potential safety risk to residents in care	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Sarah Yip LICENSING EVALUATOR NAME: David Marrufo LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022