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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708050
Report Date: 06/18/2024
Date Signed: 06/18/2024 05:01:41 PM


Document Has Been Signed on 06/18/2024 05:01 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:TERRACES AT LOS ALTOS, THEFACILITY NUMBER:
430708050
ADMINISTRATOR:GONZALES, DEBORAHFACILITY TYPE:
741
ADDRESS:373 PINE LANETELEPHONE:
(650) 948-8291
CITY:LOS ALTOSSTATE: CAZIP CODE:
94022
CAPACITY:250CENSUS: 169DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Preet KourTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Preet Kourl, Administrator.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the facility kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA Marrufo observed the first aid kit and found it to be complete.

LPA Marrufo toured 7 resident living units. Each living unit had working lights and available bedding and storage areas for clothing. LPA Marrufo toured the bathrooms in the 7 toured resident living units and two hallway bathrooms and observed each bathroom had working lights and available soap and paper towels. The water temperatures in the bathrooms ranged from 110 F to 119 F.

LPA Marrufo reviewed the Centrally Stored Medication and Destruction Records (CSMDR) for residents R1-R7. R1's CSMDR had one missing medication, one medication entered with the wrong prescription number, and four medications with no start date. R2's CSMDR had a medicatoin with the incorrect expiration date. R4's CSMDR had a medication with an incorrect expiration date. R6's CSMDR had a medication with the wrong prescription number. R7 had two medications that were missing a start date.

LPA Marrufo reviewed 7 resident records and 7 staff records and found them to be complete.

The facility maintenance record indicates the last smoke detector testing occurred on 11/09/2023. The last emergency disaster drill was conducted on 03/18/2024.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information. This report was reviewed with Administrator Preet Kourl and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
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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Document Has Been Signed on 06/18/2024 05:01 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: TERRACES AT LOS ALTOS, THE
FACILITY NUMBER: 430708050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)(E)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (E) The prescription number and the name of the issuing pharmacy


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 7 reviewed resident Centrally Stored Medication and Destruction Records, which poses/posed a potential health risk to persons in care.
POC Due Date: 06/25/2024
Plan of Correction
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Licensee agrees to conduct in-service training with all staff who handle and document resident medications on properly documenting medication prescription numbers and other relevant medication information into each resident's Centrally Stored Medication and Destruction Record by POC date. Licensee agrees to submit staff training logs to CCL once training is complete.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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