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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201931
Report Date: 07/26/2024
Date Signed: 07/26/2024 01:49:43 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/26/2024 01:49 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:RILLERA'S GUEST HOME 2FACILITY NUMBER:
445201931
ADMINISTRATOR/
DIRECTOR:		RILLERA, ZOSIMAFACILITY TYPE:
740
ADDRESS:115 GERA COURTTELEPHONE:
(831) 768-1965
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 6CENSUS: 6DATE:
07/26/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Zosima RilleraTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Annual Continuation Visit and met with Administrator Zosima Rillera.

During visit, LPA toured 3 out of 3 resident bathrooms and observed each bathroom had working lights and available soap and paper towels. LPA measured the water temperatures in each bathroom and observed that they measured between 110 F - 118 F. LPA Marrufo reviewed the Centrally Stored Medication and Destruction Records (CSMDR) for residents R1-R6. Residents R2-R4 and R6 had medications that were not recorded in their CSMDRs.

LPA Marrufo reviewed the resident records for residents R1-R6. Resident R1's and R3's records were missing Consent Forms. R4's record was missing a Safeguard for Property and Valuables Form. R4's Physician's Report states R4 has dementia and the date of the exam on the most recent Physician's Report was 06/02/2021. R5's record was missing an LIC613 Personal Rights form. R5's Physician's Report states R5 has dementia and the date of R5's most recent exam was 06/19/2018. R6's record was missing a Safeguard for Property and Valuables Form, Consent Form, and LIC613 Personal Rights Form. R6's Physician's Report states R6 has dementia and the date of R6's last exam was on 08/08/2020.

LPA reviewed staff records for staff S1-S4. Staff S1 and S4 were missing LIC9052 Employee Rights forms.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. Advisory Notes were issued. See LIC9102 Advisory Notes for more information. This report was reviewed with Administrator Zosima Rillera and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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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Document Has Been Signed on 07/26/2024 01:49 PM - It Cannot Be Edited


Created By: David Marrufo On 07/26/2024 at 01:17 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: RILLERA'S GUEST HOME 2
FACILITY NUMBER: 445201931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2024
Section Cited
CCR
87705(c)(5)

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87705 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
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Licensee agrees to arrange for an annual medical assessment for residents R4-R6 and submit updated copies of their Physician's Reports to CCL by POC date.
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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 was not met as evidenced by: Licensee did not ensure that residents with dementia R4-R6 had an annual medical assessment, which poses a potential health risk to residents in care.
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Type B
08/02/2024
Section Cited
CCR87506(b)(16)

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87506 Resident Records (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.
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Licensee agrees to submit completed copies of the Safeguard of Property and Valuables form for residents R4 and R6 by POC date.
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This requirement was not met as evidenced by: Licensee did not ensure that residents R4 and R6 had a Safeguard for Property and Valuables form on file in their resident records, which poses a potential safety risk to residents 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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/26/2024 01:49 PM - It Cannot Be Edited


Created By: David Marrufo On 07/26/2024 at 01:25 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: RILLERA'S GUEST HOME 2
FACILITY NUMBER: 445201931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2024
Section Cited
CCR
87465(h)(6)(A)-(F)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each
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Licensee agrees to audit all resident centrally stored medication and destruction records and submit a statement of understanding of the regulation 87465(h)(6)(A)-(F) to CCL by POC date.
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resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirement was not met as evidenced by: Licensee did not ensure that R2-R4 and R6 have medications missing from their centrally stored medication and destruction records, which poses a potential safety risk to residents 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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
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