Community Care Licensing

Document Has Been Signed on 08/22/2024 08:28 AM - It Cannot Be Edited

FACILITY NAME:	WESTBOROUGH MANOR 6		FACILITY NUMBER:	415600848
ADMINISTRATOR/ DIRECTOR:	TERCIANO, BELLA		FACILITY TYPE:	740
ADDRESS:	2550 CATALPA WAY		TELEPHONE:	(650) 875-9016
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY: 6		CENSUS: 6	DATE:	08/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Caregiver, Linda Mondejar		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

SUPERVISORS NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024

FACILITY NAME: WESTBOROUGH MANOR 6	FACILITY NUMBER: 415600848
	VISIT DATE: 08/21/2024

Link to Parent Document Below:

FACILITY NAME: WESTBOROUGH MANOR 6	FACILITY NUMBER: 415600848
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2024

Type A

Section Cited

CCR

87211(a)(2)

This requirement is not met as evidenced by: Facility did not report to CCL and Local Public Health when residents tested positive for COVID-19
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out 6 residents tested positive for COVID-19 and the facility did not reported to CCL and LPH which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	The Licensee will develop a signed and dated plan to CCL by 8/22/2024 to ensure the facility will be in compliance with Reporting Requirment and the plan shall indicate the date (no later than 8/28/2024) that the facility will complete the report requirement to CCL and LPH. After the reporting, the facility wil provide proof to CCL.

Section Cited

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

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024

Link to Parent Document Below:

FACILITY NAME: WESTBOROUGH MANOR 6	FACILITY NUMBER: 415600848
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2024

Type B

Section Cited

CCR

87307(a)

This requirement is not met as evidenced by: LPA observed staff living/rest area in the garage
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed staff living/rest area in the garage as which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure the garage is not being used as a living/rest area for staff and in the plan, it shall indicate a comfortable location for staff to take breaks. The Licensee will provide proof/photos that the garage is no longer being used for staff and provide a copy of the plan and photos to CCL by 8/27/2024.

Section Cited

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

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024

Link to Parent Document Below:

FACILITY NAME: WESTBOROUGH MANOR 6	FACILITY NUMBER: 415600848
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2024

Type A

Section Cited

HSC

1569.618(c)(3)

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 3 out of 3 staff did not have a current CPR and first aid training which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	The licensee will develop a signed and dated plan to CCL by 8/22/2024 indicating when the staff will be completing their CPR and first aid training (the date should be no later than 8/23/2024) and the plan shall indicate how is the facility going to prevent this from happening again.

Type A

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above 3 out of 3 staff did not have any training from 2023 to present which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	The licensee will develop a signed and dated plan to CCL by 8/22/2024 indicating when the staff will be completing their training (the date should be no later than 8/27/2024) and the plan shall indicate how is the facility going to prevent this from happening again.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024

Link to Parent Document Below:

FACILITY NAME: WESTBOROUGH MANOR 6	FACILITY NUMBER: 415600848
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2024

Type A

Section Cited

CCR

87456(a)(2)

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 6 resident did not have a copy of the pre-admission appraisal which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	The licensee will develop a signed and dated plan to CCL by 8/22/2024 indicating when the pre-admission appraisals will be completed for the 4 resident (the date should be no later than 8/27/2024) and the plan shall indicate how is the facility going to prevent this from happening again. The licensee will provide a copy of the pre-admission appraisals for all 4 residents to CCL by 8/27/2024.

Type A

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility did not have any documentation of the emergency drills which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	The licensee will develop a signed and dated plan to CCL by 8/22/2024 indicating when an emergency drill will be completed (the date shall be no later than 8/27/2024) and the plan shall indicate how is the facility going to prevent this from happening again. The administrator will provide a copy of the emergency drill in-service sign in record to CCL by 8/27/2024.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024

Link to Parent Document Below:

FACILITY NAME: WESTBOROUGH MANOR 6	FACILITY NUMBER: 415600848
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2024

Type A

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 6 residents have bedrails by the head of the bed without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	The licensee will develop a signed and dated plan to CCL by 8/22/2024 indicating when a physician's order will be obtained for the bed rails (the date should be no later than 8/27/2024). If the facility's assessment indicated the resident do not need the bed rails then the facility will provide a photo after the bed rail is removed. The plan shall indicate how is the facility going to prevent this from happening again. The licensee will provide a copy of the physician's order or the photo to CCL by 8/27/2024.

Section Cited

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

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024

Link to Parent Document Below:

FACILITY NAME: WESTBOROUGH MANOR 6	FACILITY NUMBER: 415600848
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2024

Type B

Section Cited

CCR

87611(d)

(d) In addition to Section 87463, Reappraisals and Section 8, Observation of the Resident, the licensee shall monitor the ability of the resident to provide self care for the allowable health condition and document any change in that ability. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above 5 out of 6 residents did not a reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	The licensee will develop a signed and dated plan to CCL by 8/27/2024 indicating how is the facility going to prevent this from happening again and will provide a copy of the resident's reappraisal to CCL by 8/27/2024.

Section Cited

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

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024