430702959-5-17-2024-26-AS-CDOS-D5CUV9-20240517155447

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430702959
Report Date: 05/17/2024
Date Signed: 05/17/2024 03:54:52 PM

Document Has Been Signed on 05/17/2024 03:54 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:	JULIET STEPHEN REST HOME		FACILITY NUMBER:	430702959
ADMINISTRATOR:	OLIVA, DOMINICA		FACILITY TYPE:	740
ADDRESS:	909 COLLEGE DRIVE		TELEPHONE:	(408) 298-9502
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	6	CENSUS: 4	DATE:	05/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Dominica Oliva		TIME COMPLETED:	04:00 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) Christine Dolores arrived unannounced to conduct the facility's required 1-year annual inspection. LPA met with Administrator, Dominica Oliva. During visit, LPA toured the facility to include the living room, kitchen, resident bedrooms, staff bedrooms, bathroom, common areas, garage, and exterior. All fire exit routes were free and clear of obstruction. Facility temperature maintained between 71 - 73 degrees Fahrenheit. Fire extinguisher last serviced on 04/29/2024. Carbon monoxide detector present. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 35 degrees Fahrenheit. Freezer temperature maintained at -3 degrees Fahrenheit. Items inside the refrigerator observed covered and labeled. Sharp objects, chemicals, disinfectants, and medications observed locked. Resident bedrooms equipped with beds, linens, adequate lighting, night stands, chair, and dresser. 3 residents with half bed rails has a physician's order on file. 1 resident's hospice care plan addresses the order for full bed rails. Resident bedrooms has operable door alarms and pull cords. Bathrooms equipped with grab bars, hygiene products, paper supplies, and non-slid mats. Hot water temperature maintained at 112 degrees Fahrenheit. LPA reviewed 4 resident files were complete to include an admission agreement, medical assessment, TB result, emergency contact information, consent forms, appraisal/needs and services plan, safeguard of personal property and valuables, and personal rights. LPA reviewed 4 residents centrally stored medications. SEE LIC809-C.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

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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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: JULIET STEPHEN REST HOME	FACILITY NUMBER: 430702959
	VISIT DATE: 05/17/2024

NARRATIVE

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LPA observed resident (R1) was not given 1 prescribed routine cream daily, as instructed by the physician because R1's prescription was written on the facility's medication record as a PRN. LPA observed resident (R2) was not dispensed 1.5 days of routine medication. Based on the facility's records, R2 had started the medication on 05/09/2024 but was only dispensed 7.5 out of 9 days of medication. R2's medication administration record did not show any missed medication. Facility was unable to provide reasoning. Photographs taken of R1 and R2's medication.

LPA reviewed 3 staff files were complete to include a fingerprint clearance, 1st aid certification, health screening TB result, employee rights, and training.

Facility has an emergency disaster plan. Facility has emergency lighting. Facility is conducting emergency drills quarterly, last drill was conducted in May 6, 2024. Administrator was advised. 1 resident on hospice requires an oxygen concentrator. Resident has a back-up oxygen tank. Oxygen in use signs posted on the front door.

Posters observed to include but not limited to if you see something say something, facility license, emergency disaster plan.

Documents requested to include the LIC500 and liability insurance by 05/18/2024.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Dominica Oliva and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/17/2024 03:54 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: JULIET STEPHEN REST HOME	FACILITY NUMBER: 430702959
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

(a) 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:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 4 counts which R1 was not being administered a prescribed routine cream and R2 was not administered 1.5 days of medication which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2024
	Plan of Correction
1 2 3 4	Licensee will provide all staff with training on medications. Licensee will submit the training documentation to LPA Dolores by POC due 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: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC809 (FAS) - (06/04)

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