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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430702959
Report Date: 03/16/2023
Date Signed: 03/16/2023 04:04:26 PM


Document Has Been Signed on 03/16/2023 04:04 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 HOMEFACILITY NUMBER:
430702959
ADMINISTRATOR:OLIVA, DOMINICAFACILITY TYPE:
740
ADDRESS:909 COLLEGE DRIVETELEPHONE:
(408) 298-9502
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:6CENSUS: 6DATE:
03/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Dominica and Joseph OlivaTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. During visit, violations were observed and a case management - deficiencies visit was conducted. LPA met with Licensee, Dominica Oliva and Administrator, Joseph Oliva.

LPA toured the facility with staff to include the living room, kitchen, dining room, resident bedrooms and bathrooms. During tour, LPA observed 3 out of 6 residents (R1 - R3) has full length bed rails. R1 - R3 is not under hospice care.

LPA observed residents R1 - R3 obtained a physician's order on the physician's report for full-length bed rails. Based on record review of the facility file, the facility did not submit an exception request nor obtain an approval from the Department for the use of full-length bed rails for R1 - R3.

Based on interview, the Licensee and Administrator misinterpreted the regulations but ensured they obtain a physician's order and family approval prior to the use of full-length bed rails.

No deficiencies were cited, per California Code of Regulations, Title 22. Advisory note provided. See LIC9102.

This report was reviewed with Licensee, Dominica Oliva and Administrator, Joseph Oliva and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
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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