Community Care Licensing

Document Has Been Signed on 06/29/2021 12:49 PM - It Cannot Be Edited

FACILITY NAME:	VILLA SAN LORENZO		FACILITY NUMBER:	015600676
ADMINISTRATOR:	MAMARADLO, RAZEL ZITA C.		FACILITY TYPE:	740
ADDRESS:	1179 VIA LUCAS		TELEPHONE:	(510) 397-0326
CITY:	SAN LORENZO	STATE: CA	ZIP CODE:	94580
CAPACITY: 6		CENSUS: 4	DATE:	06/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:23 AM
MET WITH:	Administrator Josefina Booker		TIME COMPLETED:	01:00 PM

SUPERVISORS NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Allison O'Hollaren LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021

Link to Parent Document Below:

FACILITY NAME: VILLA SAN LORENZO	FACILITY NUMBER: 015600676
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2021

Type B

Section Cited

CCR

87458(a)(b)

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. (b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility. (2) Documentation of prior medical services and history and current medical status including, but not limited to height, weight, and blood pressure. (3) A record of current prescribed medications, and an indication of whether the medication should be centrally stored, pursuant to Section87465(h)(1). (4) Identification of physical limitations of the person to determine his/her capability to participate in the programs provided by the licensee, including any medically necessary diet limitations. (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident’s physical condition, mental condition or both. (6) Information applicable to the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. 1 out of 4 residents (R1) did not have a physician's report on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/20/2021
	Plan of Correction
1 2 3 4	Administrator agrees to obtain a physician's report for Resident R1 and send a copy of report to CCL by fax or email by POC date.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Allison O'Hollaren LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021

Link to Parent Document Below:

FACILITY NAME: VILLA SAN LORENZO	FACILITY NUMBER: 015600676
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2021

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Smoke detector did not work in kitchen which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/06/2021
	Plan of Correction
1 2 3 4	Administrator agrees to send video of working smoke detector to CCL by POC date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Allison O'Hollaren LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021