435200712-9-6-2024-26-AS-MTAN-D8V2X3-20240906174628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200712
Report Date: 09/06/2024
Date Signed: 09/06/2024 05:47:52 PM

Document Has Been Signed on 09/06/2024 05:47 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:	CAMARGO HOME		FACILITY NUMBER:	435200712
ADMINISTRATOR/ DIRECTOR:	NAPOLEON FRANCISCO		FACILITY TYPE:	735
ADDRESS:	1911 CAMARGO DR.		TELEPHONE:	(408) 941-0712
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95132
CAPACITY: 6		CENSUS: 3	DATE:	09/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Caregiver, Emilio Hofilena		TIME VISIT/ INSPECTION COMPLETED:	06:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Marcella Tarin and David Marrufo conducted a required 1 year inspection. LPAs met with Caregiver, Emilio Hofilena due to Administrator being out sick. LPAs toured the facility inside and out. LPAs toured the kitchen. LPAs observed a 7 day supply of nonperishable food and a 2 day supply of perishable food supply. LPAs observed the refrigerator temperature at 37 degrees F and the freezer at 0 degrees F. LPAs tested 5 smoke detectors in the living and 4 out of 4 resident bedrooms. LPAs observed smoke detectors to be functioning properly. LPAs toured 2 resident bathrooms and the water temperature was recorded at 107 degrees F. 2 out of 2 resident bathrooms had soap, paper towels and functioning lights. LPAs toured 4 resident bedrooms. 4 out of 4 resident bedrooms had functioning lights, and storage space for resident belongings. LPAs reviewed 3 Centrally Stored Medication and Destruction Records (CSMDR). 2 out of 3 CSMDRs were reviewed as complete. Resident 2 (R2) and Resident 3 (R3) CSMDRs were reviewed as complete. Resident 1 (R1) was missing 3 medications on the CSMDR. LPAs reviewed 3 out of 3 Personal and Incidental Money (PNI) logs. 3 out of 3 PNI logs were complete. LPAs reviewed 3 resident records. R1-R3 resident records were missing consent forms. R2 and R3 resident records were missing LIC613C (Personal Rights). LPAs reviewed 4 staff records. 1 out of 4 staff records were reviewed as complete. Staff 1 (S1)'s record was complete. S2-S4 staff records did not contain employee rights LIC9052. See LIC809-C for more information. Page 1 of 2.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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 4

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: CAMARGO HOME	FACILITY NUMBER: 435200712
	VISIT DATE: 09/06/2024

NARRATIVE

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Emergency drills logs were reviewed. Last drill conducted on 6/8/2024.

LPAs observed a chair in R2's room obstructing the exit through the sliding door. LPAs observed boxes outside R2's bedroom obstructing the exit through R2's sliding bedroom door. A recliner chair in R2's bedroom between R2's bed and R2's closet and in front of the sliding exit door in R2's bedroom was observed in R2's bedroom. During interview, Staff S1 stated the reclining chair was placed there to prevent R2 from entering the closet. LPAs observed there were no alarms on R1 and R2's sliding glass doors.

R2's bedroom smelled like urine.

LPAs observed a box of vegetables obstructing exit through the living room sliding door.

LPA's observed the first step in the garage steps was loose during visit.

R1's bedroom had a screw in a hole made in the top track of the sliding doorway obstructing the sliding door from completely sliding open. LPAs observed a hole drilled into the top of the sliding glass door track and a screw placed in the hole. Staff S1 stated the nail was placed on the top of the sliding glass door track to prevent a prior resident who was deceased around a year ago from leaving the bedroom.

LPA's observed R1's bedroom entrance door was scraping the floor.

LPAs reviewed R1 and R2s physician's reports and Appraisal needs and service plans and did not observe any documented wandering behaviors for R1 and R2 nor any preventative behaviors that staff need taken to prevent R1 or R2 from wandering.

1 out of 2 outdoor exits has garbage containers, a painting and other disposed items obstructing the exit.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. Advisory Notes were issued. See LIC9102 pages for more information. This report was reviewed with Emilio Hofilena and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 09/06/2024 05:47 PM - It Cannot Be Edited

Created By: Marcella Tarin On 09/06/2024 at 04:41 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: CAMARGO HOME	FACILITY NUMBER: 435200712
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(c)

80087 Buildings and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction 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. LPAs observed a chair in R2's room obstructing the exit through the sliding door. LPAs observed boxes outside R2's bedroom obstructing the exit through R2's sliding bedroom door. A recliner chair in R2's bedroom between R2's bed and R2's closet and in front of the sliding exit door in R2's bedroom was observed in R2's bedroom. During interview, Staff S1 stated the reclining chair was placed there to prevent R2 from entering the closet. LPAs observed there were no alarms on R1 and R2's sliding glass doors, which poses an immediate safety risk to residents in care.
	POC Due Date: 09/07/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit plan of correction and pictures of removal of reclining chair from R2s room and removal of boxes outside of R2s bedroom, removal of boxes outside outside of living room sliding door, and removal of garbage container, a painting and other disposed items in 1 out of 2 outdoor exits. Licensee will submit pictures to LPA Tarin via email by POC due date.

Type A

Section Cited

CCR

80087(a)

80087 Buildings and Grounds (a) the facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited. LPAs observed R2's bedroom smelled like urine, LPAs observed a box of vegetables obstructing exit through the living room sliding door. LPA's observed the first step in the garage steps was loose during visit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2024
	Plan of Correction
1 2 3 4	Licensee will submit a plan of correction by POC due date how the urine smell will be removed, the garage step will be repaired and the door in R1's room will be repaired to not scrape the floor. Licensee will submit statement to LPA Tarin via email by POC due date.

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:

Jin Jackie

LICENSING EVALUATOR NAME:

Marcella Tarin

LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/06/2024 05:47 PM - It Cannot Be Edited

Created By: Marcella Tarin On 09/06/2024 at 05:01 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: CAMARGO HOME	FACILITY NUMBER: 435200712
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80072(a)

80072 (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (7) Not to be locked in any room, building, or facility premises by day or night. 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. LPAs observed R1's bedroom had a screw in a hole made in the top track of the sliding doorway obstructing the sliding door from completely sliding open. LPAs observed a hole drilled into the top of the sliding glass door track and a screw placed in the hole. Staff S1 stated the nail was placed on the top of the sliding glass door track to prevent a prior resident who was deceased around a year ago from leaving the bedroom which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2024
	Plan of Correction
1 2 3 4	Licensee will submit a plan of correction stating how the licensee will remove the screw in the sliding doorway track to CCL by POC due date.

Type A

Section Cited

CCR

80075(k)

80075 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:(A) The name of the client for whom prescribed.(B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy.(F) Expiration date. (G) Number of refills. (H) Instructions, if any, regarding control and custody of the medication. 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 comply with the section cited above. LPAs reviewed 3 Centrally Stored Medication and Destruction Records (CSMDR). 2 out of 3 CSMDRs were reviewed as complete. Resident 2 (R2) and Resident 3 (R3) CSMDRs were reviewed as complete. Resident 1 (R1) was missing 3 medications on the CSMDR which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2024
	Plan of Correction
1 2 3 4	Licensee will submit a plan of correction stating how the licensee will ensure that CSMDRs are complete for each resident. Licensee will submit plan via email to CCL by POC due date.

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:

Jin Jackie

LICENSING EVALUATOR NAME:

Marcella Tarin

LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4