415600267-9-21-2023-26-AS-DMAO-CVVVDA-20230921162025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600267
Report Date: 09/21/2023
Date Signed: 09/21/2023 04:20:37 PM

Document Has Been Signed on 09/21/2023 04:20 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:	WRIGHT PLACE, THE		FACILITY NUMBER:	415600267
ADMINISTRATOR:	WRIGHT, JO ANN		FACILITY TYPE:	740
ADDRESS:	2525 ANNAPOLIS ST.		TELEPHONE:	(650) 329-0911
CITY:	EAST PALO ALTO	STATE: CA	ZIP CODE:	94303
CAPACITY:	6	CENSUS: 1	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jo Ann Wright		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Jo Ann Wright, Administrator (ADM). During visit, LPA Marrufo observed that ADM was preparing food in aluminum trays in the kitchen. ADM stated that ADM has a job today delivering catered food to a board meeting. ADM stated she is getting paid for the catered food. LPA Marrufo observed food trays, a baked cake that ADM stated she baked in the facility kitchen, a pot of gravy, and a propane-powered stove in the outside of the facility with a pot of heated oil. LPA Marrufo observed a tray of fish covered in flower that ADM stated she will cook in the outdoor stove. LPA Marrufo reviewed the resident records. LPA Marrufo observed that there were 2 medications without prescription labels and two bottles of medications that had the incorrect amount of pills based on the start date. LPA Marrufo observed resident R1's Appraisal/Needs and Services Plan was missing 2 out of 4 pages and was not signed by client or client's representative. R1's Safeguard for Property/Valuables is not the official LIC form and does not have client's signature/initials. LPA Marrufo toured the kitchen area and found 4 cans of expired food. LPA Marrufo observed 2 out of 2 bathrooms and observed the water temperature to be 125 F. LPA Marrufo tested the facility carbon monoxide detectors and smoke alarms. 2 out of 2 carbon monoxide detectors functioned properly when tested. 4 out of 7 smoke detectors functioned when tested but had a very faint alarm sound when tested. ADM stated during visit to have conducted an emergency disaster drill, but does not keep an emergency disaster drill log. See LIC809-C for more information. Page 1 of 2.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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 5

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: WRIGHT PLACE, THE	FACILITY NUMBER: 415600267
	VISIT DATE: 09/21/2023

NARRATIVE

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LPA Marrufo observed 2 out of 2 bathrooms. Each bathroom had available soap, paper towels, and showers with chairs, hand railings, and mats. The water temperature measured at 115 F in 2 out of 2 bathrooms.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information.

A civil penalty of $250 was issued for a repeated violation.

An Advisory Note was issued. See LIC9102 for more information.

This report was reviewed with ADM Jo Ann Wright and a copy of the report and appeal rights were provided.

Page 2 of 2. END REPORT.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 09/21/2023 04:20 PM - It Cannot Be Edited

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: WRIGHT PLACE, THE	FACILITY NUMBER: 415600267
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87205(a)

The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement is not met as evidenced by: Licensee/Administrator has operated a catering service business at the facility, which poses an immediate safety risk to residents in care. *Repeated Violation *
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit plan of correction by POC date to CCL stating how licensee plans on preventing her catering business and any other business or activity which is not related to the licensing of the facility to be conducted at the facility.

Type A

Section Cited

CCR

87555(b)(8)

87555(b)(8) General Food Service Requirements: (b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: This requirement was not met as evidenced by: LPA observed 4 expired cans in the pantry, which poses an immediate safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a plan of correction by POC date to CCL stating how the licensee plans to audit the facility food supply and ensure that all expired foods are disposed.

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	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 09/21/2023 04:20 PM - It Cannot Be Edited

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: WRIGHT PLACE, THE	FACILITY NUMBER: 415600267
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

87506 Resident Records(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: This requirement was not met as evidenced by: During record review, LPA observed resident R1 was missing 2 out of 4 pages of the Appraisal/Needs and Services Plan and it was not signed by client or client's representative, and R1’s Safeguard for Property/Valuables is not the official LIC form and does not have client's signature/initials, which poses a potential safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Licensee agrees to create a completed and signed Appraisal/Needs and Services Plan and Safeguard for Property/Valuables forms for R1 and submit copies of the documents to CCL by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 09/21/2023 04:20 PM - It Cannot Be Edited

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: WRIGHT PLACE, THE	FACILITY NUMBER: 415600267
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

87465 Incidental Medical and Dental Care (a)(4): A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: This requirement was not met as evidenced by: LPA observed R1 had 2 missing pills of Eliquis and 3 pills of Spironolactone that should have been used by June 23rd, 2023.
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a plan by POC date to CCL to ensure that all medications are given to residents according to prescription and are accurately logged when administered.

Type A

Section Cited

CCR

87465(e)(1-4)

87465 Incidental Medical and Dental Care (e)(1-4): For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (1) The specific symptoms which indicate the need for the use of the medication. (2)The exact dosage. (3) The minimum number of hours between doses. (4) The maximum number of doses allowed in each 24-hour period. This requirement was not met as evidenced by: LPA observed 2 of R1’s medications did not have a prescription label on them, which poses an immediate safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a plan of correction by POC date to CCL to ensure that all medications have a prescription label attached to them.

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	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5