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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200383
Report Date: 01/23/2025
Date Signed: 01/23/2025 02:18:31 PM

Document Has Been Signed on 01/23/2025 02:18 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:LA SELVAFACILITY NUMBER:
435200383
ADMINISTRATOR/
DIRECTOR:		JIM MILLSAPFACILITY TYPE:
772
ADDRESS:652 FOREST AVENUETELEPHONE:
(650) 323-1401
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY: 12CENSUS: 8DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Michelle Ly, Sajana Sagar, Julia PhillipsTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On January 23, 2025, at 09:00 AM, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the Director of Admissions, Michelle Ly, and disclosed the purpose of the inspection. The Director of Operations (DO), Sajana Sagar, and Director of Quality Improvement (DI), Julia Phillips joined shortly after. The DO informed the LPA that the facility had (8) clients in care and (5) staff members present at the time. (7) clients were away at their day program and (1) client was at the facility.

At 9:48 AM, the LPA initiated a walk-through of the facility, accompanied by the DO.

LPA inspected the kitchen and found it clean, with no food preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The sink was empty, and no dirty dishes were observed. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted. LPA inspected the fire extinguisher mounted on the wall in the kitchen and found it fully charged, with the last service tag dated 11/26/2024.

LPA inspected the dining area adjacent to the kitchen and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. A non-slip rug was placed under the dining table and chairs. The LPA observed playing cards, board games, puzzles, and other recreational activity items for the clients in the dining area.

LPA inspected a locked closet in the hallway, containing detergents, soap, and cleaning supplies. The DO tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional.

Continued on 809-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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: LA SELVA
FACILITY NUMBER: 435200383
VISIT DATE: 01/23/2025
NARRATIVE
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Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit. LPA inspected a locked container containing knives and sharp objects in the main office room. The indoor temperature reading of 72°F on a thermostat was observed in the hallway at the time of the visit.

LPA inspected the living room and observed it clean, with all furniture in good repair. There were sofas, chairs, television, piano, karaoke system, coffee table, and a rug under the furniture in the living room. Books, games, and other items for clients’ planned activities were also observed.

There were (4) bedrooms and (3) bathrooms designated for clients' use. All client rooms were shared occupancy. LPA inspected (1) client bedroom on the first floor and (3) client bedrooms on the second floor, and found them clean, well-lit, and equipped with the required furniture. LPA inspected (1) bathroom on the first floor and (2) bathrooms on the second floor, and found them clean, sanitary, and in good working condition. The bathrooms contained soap, paper towels, a trash can, and non-slip mats. The hot water temperature at the sink faucet measured 118.6°F in bathroom on the first floor and 116.8°F in bathroom on the second floor.

LPA inspected the basement and observed (2) washers, (1) dryer, refrigerator containing additional food supplies, and (4) closets containing towels, paper products, laundry soap, cleaning supplies, snacks, cereals, and other dry food products were observed.

LPA toured the backyard area and found all passageways in good condition, clear of obstructions, with no blocking or tripping hazards. No accessible bodies of water were found. A shaded area with outdoor patio furniture in good clean condition were observed.

LPA reviewed (5) staff personnel records and (5) client records. The LPA observed that 5 of 5 clients had an Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members were associated with the facility.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted monthly, with the most recent drill completed on 11/26/2024.

Continued on 809-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
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: LA SELVA
FACILITY NUMBER: 435200383
VISIT DATE: 01/23/2025
NARRATIVE
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LPA observed a locked centrally stored medication cabinet inside the staff office. Medications were organized in separate bins for each client. Centrally Stored Medication and Destruction Records (CSMDR) were reviewed. 1 of 11 medication was found in the medication bin for client (R3) was not listed on CSMDR and was not found in the Physician’s report for R3 aand there was no Physician's order for this medication. 1 of 11 medication listed on CSMDR was entered with a wrong prescription number and the wrong name of the issuing pharmacy.

The following updated forms are requested to be submitted to CCLD by 01/30/2025:

  • LIC 500: Personnel Report
  • LIC 308: Designation of Facility Responsibility
  • Certificate of Liability Insurance
  • Administrator Certificate(s)

The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Director of Quality Improvement. A copy of this report and appeal rights were discussed and left with the Director of Quality Improvement, Julia Phillips, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 02:18 PM - It Cannot Be Edited


Created By: Kiran Jain On 01/23/2025 at 01:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LA SELVA
FACILITY NUMBER: 435200383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and records review, the licensee did not ensure to centrally log in CSMDR and have a physician's order for 1 out of 11 medications (Simvastatin) for client (R3). This medication 'Simvastatin' was administered to R3 and was logged in Medication Administration Record (MAR) for the dates it was administered to R3, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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The licensee will audit the timeline of client’s chart to figure out where the error occurred and will wait for the physician to clear it before further administering the medication to the client. The licensee will provide documentation of the findings to CCLD by 01/24/2025.
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:April Cowan
LICENSING EVALUATOR NAME:Kiran Jain
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 02:18 PM - It Cannot Be Edited


Created By: Kiran Jain On 01/23/2025 at 01:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LA SELVA
FACILITY NUMBER: 435200383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not ensure to centrally log the correct medication prescription number and correct name of the issuing pharmacy in CSMDR for 1 out of 11 medications (Enalapril) for client (R3). This medication Enalapril was administered to R3 and was logged in Medication Administration Record (MAR) for the dates it was administered to R3, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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The licensee will implement stronger safeguards internally to make sure this error doesn’t happen again. A training will be provided to accurately log the medication and match the prescription details of the medication. The licensee will provide the evidence of the training to CCLD by 01/30/2025.
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:April Cowan
LICENSING EVALUATOR NAME:Kiran Jain
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


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