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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200344
Report Date: 07/23/2024
Date Signed: 07/23/2024 06:59:10 PM


Document Has Been Signed on 07/23/2024 06:59 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:FORUM AT RANCHO SAN ANTONIO, THEFACILITY NUMBER:
435200344
ADMINISTRATOR:ROSALIE B ZBASNIK-HULOGFACILITY TYPE:
741
ADDRESS:23500 CRISTO REY DRIVETELEPHONE:
(650) 944-0100
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:817CENSUS: 518DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator, Rosalie Zbasnik/HulogTIME COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA met with Administrator (ADM) Rosalie Zbasnik/Hulog and stated the purpose of today's visit.

During visit, LPA Rai toured the inside and outside of the facility to include the assisted living unit and memory care unit. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. LPA Rai observed the temperature of the freezer at 0 degrees F and the temperature of the fridge at 37 degrees F. LPA Rai observed storage unit for emergency food supply and two back-up generators on the premise.

LPA Rai randomly toured 10 resident bedrooms. 10 Out of 10 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathrooms had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 108.7 degrees F - 119.7 degrees F.

Fire extinguisher was observed and inspected on 10/17/2023. Facility smoke detectors and sprinklers were in working condition and inspected by a third party vendor on 5/1/2024 and 7/19/2024. The last disaster drill was conducted on 03/18/2024 and 6/21/2024.

LPA Rai reviewed facility records for 10 staff and 11 residents. LPA Rai observed 6 out of 11 Appraisal/Needs and Services Plan was not signed by resident and/or responsible party. LPA Rai observed the facility Individual Service Plan was not signed by resident and/or responsible party. LPA Rai reviewed at random 10 resident current and PRN medications and central stored medication records.

Deficiencies were cited per California Code of Regulations, Title 22 and Technical Violation was provided. This report was reviewed with Administrator (ADM) Rosalie Zbasnik/Hulog and a copy of the report was provided. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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 07/23/2024 06:59 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: FORUM AT RANCHO SAN ANTONIO, THE
FACILITY NUMBER: 435200344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2024
Section Cited
CCR
87463(b)

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87463 Reappraisals
(b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person.
This requirement was not met as evidenced by:
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Administrator stated to submit a written plan of action understanding regulation and will ensure Appraisal/Needs and Services Plan is signed by resident and/or responsible party by POC due date. Administrator agreed and understood.
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Based on record review and interview, 6 out of 11 resident files did not contain Appraisal/Needs and Services Plan and Individual Service Plan signed by resident and/or responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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