435200735-12-16-2023-26-AS-SRAI-CYL2NV-20231216163321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200735
Report Date: 12/16/2023
Date Signed: 12/16/2023 04:33:29 PM

Document Has Been Signed on 12/16/2023 04:33 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:	HOMESIDE RETREAT		FACILITY NUMBER:	435200735
ADMINISTRATOR:	REBOTON, C. FLORO		FACILITY TYPE:	735
ADDRESS:	3330 BIEN WAY		TELEPHONE:	(408) 531-8640
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY: 6		CENSUS: 5	DATE:	12/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Administrator Designee, Kathleen Anne Reboton		TIME COMPLETED:	04:45 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) Simi Rai & Mita Partoza conducted an unannounced Required 1 Year visit and met with Administrator Designee, Kathleen Anne Reboton. LPAs Rai & Partoza observed 3 staff and 5 residents at the facility. During visit, LPAs Rai & Partoza toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai & Partoza toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPAs observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. The facility bathroom had available soap, paper towels, and trash cans with lids. The shower had grab bars and non-skid mats. The water temperature in the bathroom sinks ranged from 113.7F to 116.4F. The water temperature in the kitchen sink was 121.4F. Fire extinguisher was observed and inspected on Sept. 12, 2023. Facility smoke detectors and carbon monoxide detectors were in working condition. 3 out of 3 resident bedrooms had available bedding, drawers, and functioning lights. LPA Rai & Partoza reviewed facility records for 2 staff and 3 residents. LPA Rai & Partoza reviewed resident medications and central stored medication records. During a random review/audit of resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record. LPAs along with Administrator Designee counted the tablets from the medication bottles. LPAs reviewed R1's Centrally Stored Medication Records with the stored medications. Continuation on LIC 809-C, Page 1 of 2.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023

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 3

Document Has Been Signed on 12/16/2023 04:33 PM - It Cannot Be Edited

Created By: Simranjit Rai On 12/16/2023 at 03:27 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: HOMESIDE RETREAT	FACILITY NUMBER: 435200735
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80065(a)

80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, interview and observation R1's 4 out of 6 medications not administered to R1 as prescribed by the MD which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 12/17/2023
	Plan of Correction
1 2 3 4	Administrator Designee stated the staff will be provided in-service training, ensure resident's Medication Admnistraor Records (MARs) is accurate and submit a written plan of action by POC date. Administrator Designee agreed and understood.

Type A

Section Cited

CCR

80012

80012 False Claims (a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, interview and observation, R1's Medication Administration Records (MARs) show medication was administered for 1 out of 6 medications but the medication count was not accurate, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 12/17/2023
	Plan of Correction
1 2 3 4	Administrator Designee stated to submit a plan of action understanding regulation and will ensure MARs is accurate by POC due date. Administrator Designee agreed and understood.

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:

Simranjit Rai

LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: HOMESIDE RETREAT	FACILITY NUMBER: 435200735
	VISIT DATE: 12/16/2023

NARRATIVE

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LPAs reviewed R1's medication and 4 out of 6 medications prescribed to R1 was not given as prescribed by the doctor. R1's medication #1 were counted 84 tablets instead of 80 tablets. Per Medication Administration Record, R1 has not missed dose of medication and per S1 and AD, R1 had not refused medication. R1's medication #4 was counted at 128 tablets when there should be 118 tablets in the bottle. LPAs and AD reviewed the facility's Medication Administration Record (MAR) and medication has been accounted for each dose since the bottle was opened. AD spoke to R1 and R1 stated R1 did not take medication tablets and R1 returned medication tablets to facility staff and facility staff returned the medication in the bottle. Per MAR, the medication tablet was administered to R1, documenting the tablets were administered to R1. R1's medication #5 and medication #6 was not recorded on MARs, AD stated R1 sometimes takes the medication as needed, but the physician's order stated the medication needs to be taken daily.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
80065 Personnel Requirements is being cited during today's visit. LPAs would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs.

Exit interview was conducted with Administrator Designee, Kathleen Anne Reboton. A copy of this report was provided to Administrator Designee, Kathleen Anne Reboton. Appeal Rights were provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023

LIC809 (FAS) - (06/04)

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