Community Care Licensing

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024

Document Has Been Signed on 09/26/2024 12:30 PM - It Cannot Be Edited

FACILITY NAME: VANESSA CARE HOME II	FACILITY NUMBER: 410508446
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2024

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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, as detached storage shed in backyard is not locked, and Lysol liquid cleaner and laundry cleaning fluids are stored inside. This poses an immediate health, safety or personal rights risk to persons in care, as cleaning liquids are not secured.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Padlock was installed on storage shed in LPA's presence. Deficiency corrected and cleared.

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 in 1 out of 5 resident rooms, as Centrum multivitamins, Vitamin C, Milk of Magnesia, Tylenol and Magnesium are stored in room #3, where client #1 resides. Client is not able to self store and administer medications, per MD. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Supplements and Tylenol were removed from room #3 in LPA's presence. Deficiency corrected and cleared.

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024

Document Has Been Signed on 09/26/2024 12:30 PM - It Cannot Be Edited

FACILITY NAME: VANESSA CARE HOME II	FACILITY NUMBER: 410508446
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2024

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff record review, the licensee did not comply with the section cited above in 2 out of 5 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care. - Health screenings and TB test results for staff #2 and #4 are not on file.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	Copies of health screenings and TB test results for staff #2 and #4 will be sent to CCLD BY DUE DATE

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024

Document Has Been Signed on 09/26/2024 12:30 PM - It Cannot Be Edited

FACILITY NAME: VANESSA CARE HOME II	FACILITY NUMBER: 410508446
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2024

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff record review, the licensee did not comply with the section cited above, as there is no documentation that caregivers have received required 8 hours of annual dementia training and 4 hours of annual hospice care, restricted health conditions, and postural supports training. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	Staff #4 and #5 will receive at least 8 hours of dementia training and 4 hours of hospice care, restricted health conditions and postural supports training annually, and BY DUE DATE. Proof of training to be sent to CCLD BY DUE DATE.

Type B

Section Cited

HSC

1569.69(a)(2)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff record review, the licensee did not comply with the section cited above, as there is no evidence that caregivers have received required 8 hours of annual medications training. This poses a potential health, safety or personal rights risk to persons in care. - There is no evidence that staff #4 and #5 have received required 8 hours of annual medications training.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	Staff who handle medications will receive annual medications training and at least 8 hours of medications training by DUE DATE. Proof of training to be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024

Document Has Been Signed on 09/26/2024 12:30 PM - It Cannot Be Edited

FACILITY NAME: VANESSA CARE HOME II	FACILITY NUMBER: 410508446
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2024

Type B

Section Cited

CCR

87705(c)(5)

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 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 is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on client record review, the licensee did not comply with the section cited above, as client #5 is diagnosed with dementia, and appraisal is dated in 2019. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	Appraisal/Needs and Services Plan for client #5 will be updated, signed and dated. Copy to be sent to CCLD BY 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
1 2 3 4	Based on client record review, the licensee did not comply with the section cited above, as there is no MD order for half bed rails for client #4, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	MD order for half bed rails for client #4 will be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024

Document Has Been Signed on 09/26/2024 12:30 PM - It Cannot Be Edited

FACILITY NAME: VANESSA CARE HOME II	FACILITY NUMBER: 410508446
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2024

Type A

Section Cited

CCR

87468.1(a)(6)

PERSONAL RIGHTS To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. 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 in 1 out of 5 residents rooms observed, which poses an immediate health, safety or personal rights risk to persons in care. Client #2 resides in room 1 with a sliding glass door, which is secured with a screw so client cannot access the door "because she escapes," per staff.
	POC Due Date: 09/23/2024
	Plan of Correction
1 2 3 4	Screw was removed from sliding glass door in LPA's presence. Licensee to submit plan of correction describing how client will be monitored by staff without securing exit door shut.

Section Cited

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

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024