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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200488
Report Date: 01/26/2024
Date Signed: 01/26/2024 04:16:23 PM


Document Has Been Signed on 01/26/2024 04:16 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
Lookup Error,
, CA



FACILITY NAME:HOLY SPIRIT RESIDENTIAL CAREFACILITY NUMBER:
435200488
ADMINISTRATOR:ANCHETA, CORINAFACILITY TYPE:
740
ADDRESS:262 LAKEMUIR DRIVETELEPHONE:
(408) 245-2405
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:6CENSUS: 6DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Corina AnchetaTIME COMPLETED:
04:20 PM
NARRATIVE
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On 1/26/2024, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self, stated purpose of visit, and allowed entrance by caregiver. Licensee/Administrator contacted by telephone and arrived a short time later to conduct inspection.

Currently, six (6) residents in care. All residents present during inspection. Residents observed watching television in the living room or relaxing in their room. Facility tour began in resident bedrooms. Rooms observed to have all required accommodations. LPA observed beds for R1, R2, R3, R4, and R5 have 1/2 bed rails with no doctors orders. All areas of the facility have sufficient lighting. Residents bathrooms observed to be clean and in good repair. Bath/tub are have non-skid mats and grab bars. Hot water tested in resident bathroom with a water temperature of 108 degrees F. Dining room and living room have adequate seating and lighting for all residents in care. Tour of kitchen conducted. LPA observed adequate food supply for the residents in care. LPA observed leftovers stored in the refrigerator and/or freezer observed to be properly stored and labeled. Medications observed to be locked in medication cart near kitchen area.

Smoke Alarms tested & observed to be operational at time of visit. Carbon monoxide detector present and visible in hallway near resident bedrooms. Fire extinguisher has a service date of 1/04/2023. All cleaning supplies observed to be locked in secured under kitchen sink and in garage.

Outside areas toured. All exits open freely and observed to be free of obstruction. No hazards observed.

Staff and resident files reviewed

Deficiency cited on attached 809D. Exit interview conducted with Administrator and copy provided for facility records.
SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/26/2024 04:16 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
Lookup Error,
, CA


FACILITY NAME: HOLY SPIRIT RESIDENTIAL CARE
FACILITY NUMBER: 435200488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
(a)Based on the individual's preadmission appraisal….Postural supports may be used under the following conditions…(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 5 out of 6 persons had 1/2 bed rails without a doctor's order which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Licensee to submit doctor's ordersn for half bed rails for residents (R1, R2, R3, R4 and R5) to LPA no later than POC due date.
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: Brenda WhiteTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2