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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200466
Report Date: 07/18/2024
Date Signed: 07/18/2024 05:06:35 PM

Document Has Been Signed on 07/18/2024 05:06 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MADERA VILLA RESIDENTIAL CAREFACILITY NUMBER:
435200466
ADMINISTRATOR/
DIRECTOR:		TUAN, ALANFACILITY TYPE:
740
ADDRESS:1052 W. IOWA AVENUETELEPHONE:
(408) 739-7368
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 15CENSUS: 12DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:59 PM
MET WITH:Alan TuanTIME VISIT/
INSPECTION COMPLETED:
04:39 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Alan Tuan.

12 residents and 4 staff were observed in the facility. License, an expired Administrator Certificate, and personal rights posters were observed in the facility. ADM provided the documents that he/she renewed the Administrator Certificate already.

LPA reviewed 6 resident files and 4 staff files. One resident file was observed without Appraisal/Needs and Service form. 2 resident files were observed the centrally stored medication forms were not updated and not matching with the medications.

LPA toured the facility inside out with ADM. 15 resident single rooms, 1 staff live-in room, 1 office, 1 storage room, living room, dining room, two common restrooms and kitchen were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient.

Medication room was observed locked. Knives closet was observed unlocked, ADM locked the knives closet immediately. Cleaning product closet were observed unlocked. ADM put an lock and locked the cleaning product closet before LPA finished the inspection.

Room temperature was at 76 degree F, and hot water temperature was at 118 degree F in facility.
Emergency light system, first aid box, night lights, and flash lights were observed at the facility. ADM and LPA tested the signal system, and it works fine. The last time the facility conducted the emergency drill is 7/10/2024.

Continue on LIC809-C. Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MADERA VILLA RESIDENTIAL CARE
FACILITY NUMBER: 435200466
VISIT DATE: 07/18/2024
NARRATIVE
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Fire extinguisher was serviced on 7/10/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and it was working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. One storage room was observed at the backyard.

Deficiency was noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.


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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/18/2024 05:06 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 07/18/2024 at 04:01 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: MADERA VILLA RESIDENTIAL CARE
FACILITY NUMBER: 435200466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)(2)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage.

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 that 2 out of 6 residents' centrally stored medication forms were not updated and were not matched with medications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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Administrator stated to send a plan of correction by the POC due date and to provide staff training for documentation for medications. ADM stated to send the staff training log to CCL office.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(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
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Based on record review, the licensee did not comply with the section cited above in that 1 out of 6 resident does not have valid appraisal/needs service plan in the resident file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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Administrator stated to submit a plan of correction to CCL office to maintain a valid appraisal needs and service plan for residents.
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 Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
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