Community Care Licensing

SUPERVISOR'S NAME: Sarah Yip TELEPHONE: (408) 324-2131 LICENSING EVALUATOR NAME: Christine Dolores TELEPHONE: (408) 334-8552 LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023

Document Has Been Signed on 06/02/2023 01:55 PM - It Cannot Be Edited

FACILITY NAME: COLLEGE MANOR	FACILITY NUMBER: 430708150
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

Type B

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above by having the hot water temperature at 140 degree F which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	Licensee adjusted the water temperature during visit. Licensee will take a picture of the hot water temperature and send the picture to LPA by POC due date.

Type B

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, and record review the licensee did not provide facility staff with annual training in 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	Licensee will provide staff training annually. Licensee will submit a statement of understanding of the section cited above to LPA by POC due date.

SUPERVISOR'S NAME: Sarah Yip TELEPHONE: (408) 324-2131 LICENSING EVALUATOR NAME: Christine Dolores TELEPHONE: (408) 334-8552 LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023

Document Has Been Signed on 06/02/2023 01:55 PM - It Cannot Be Edited

FACILITY NAME: COLLEGE MANOR	FACILITY NUMBER: 430708150
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

Type B

Section Cited

CCR

87463(c)

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the residents appraisal needs and services plans were updated more than 12 months ago which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	Licensee will submit a statement of understanding that all appraisal needs and services plans will be updated yearly to LPA by POC due date.

Section Cited

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

SUPERVISOR'S NAME: Sarah Yip TELEPHONE: (408) 324-2131 LICENSING EVALUATOR NAME: Christine Dolores TELEPHONE: (408) 334-8552 LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023

FACILITY NAME: COLLEGE MANOR	FACILITY NUMBER: 430708150
	VISIT DATE: 06/02/2023

NARRATIVE

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2 out of 2 bathrooms supplied with hand soap, paper towels and hand washing signs. Showers equipped with grab bars, non-slid mats, and shower chairs. Bathroom #1 hot water temperature maintained at 140 degrees F. During visit, staff lowered the hot water temperature. LPA observed the hot water temperature maintained at 130 degrees F. Licensee was advised. Facility has an emergency disaster plan. During visit, Licensee placed the emergency disaster plan in a visible area. It was observed 1 out of 2 facility emergency lighting in the hallway was non-operable. Facility was only equipped with 1 flash light that did not contain batteries. During visit, a staff member arrived with 6 flashlights and placed them in every residents bedroom. Facility has a complete first aid kit. Facility last conducted an emergency drill in January 2023. Licensee was advised to conduct a drill at least quarterly. Fire extinguisher last serviced on 05/03/2023. Facility is equipped with an operable carbon monoxide detector. LPA reviewed 4 out of 6 residents files contained an up-to-date physician's report, TB information, admission agreement, emergency contact form, personal rights form, consent forms, safeguard of personal properties, pre-admission, and appraisal needs and services plan. 4 out of 6 residents appraisal needs and services plan was more than 1 year old. Licensee was advised. During visit, Licensee began updating residents appraisal needs and services plan. LPA inspected 3 out of 6 residents centrally stored medications. Licensee was verbally advised to ensure the centrally stored medication records are filled out completely and accurately. LPA reviewed 3 staff files contained an up-to-date 1st Aid Certification, health screening form with TB information, and training in January - March 2022. Staff members present are fingerprint cleared and associated to the facility. LPA did not observe facility staff were provided training in 2023. Licensee was advised. 5 residents and 3 staff members were interviewed. Posters observed to include Ombudsman, if you see something say something, facility sketch, and COVID-19 poster. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. Advisory notes provided. This report was reviewed with Licensee, Dominica Oliva and a copy of the report and appeal rights were provided.