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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200964
Report Date: 08/15/2024
Date Signed: 08/15/2024 05:09:27 PM

Document Has Been Signed on 08/15/2024 05:09 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:MERTZ CARE HOME IVFACILITY NUMBER:
435200964
ADMINISTRATOR/
DIRECTOR:		MERTZ, ELVIRAFACILITY TYPE:
735
ADDRESS:2591 BOREN DRIVETELEPHONE:
(408) 947-0825
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Staff Corazon GrimaresTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff Corazon Grimares. During the visit, LPA observed 6 residents and 3 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with staff S1 which included the Living room, kitchen, dining room, one hallway restroom and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected.

While touring the facility living room, LPA's observed two brown couches obstructing exit #3. LPA also observed the emergency disaster plan for adult day programs, (LIC610D). The LIC610D states the sliding door at the living room is a facility exit. While touring the backyard of the facility, LPA's observed a mattress, on the ramp directly next to the exit #4. Exit #4 is also indicated as an exit on the LIC610D. LPA's interview staff S1 and S2. Staff S2 stated the couches were placed in front of that exit by the morning staff because R1 likes to AWOL. While touring the facility garage, LPA's observed the door to the outside (Exit #2) was obstructed by a black trash container. The LIC610D states the garage door is also a facility exit location.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 117 degrees F in both resident bathrooms.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MERTZ CARE HOME IV
FACILITY NUMBER: 435200964
VISIT DATE: 08/15/2024
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Fire extinguisher was serviced in January 26, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on May 12, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident P&I records LPA conducted interviews with 3 staff and 3 residents.

LPA reviewed 3 resident medications and centrally stored medication records. While reviewing R3's medications, LPA observed medication #1 was not listed in R3's Centrally stored Medication Record. LPA asked staff Corazon Grimares to find medication #1 in R3's Centrally stored medication record. Staff Corazon Grimares was unable to show LPA's medication #1 listed in R3's Centrally stored medication log.

Deficiencies are being cited during today's visit. This report was reviewed with Staff Corazon Grimares and a copy of the signed report was provided. LPA's called Lead staff Rogeline Jimeniz and reviewed the report. Appeal rights were provided.

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END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/15/2024 05:09 PM - It Cannot Be Edited


Created By: Manuel Monter On 08/15/2024 at 04:49 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: MERTZ CARE HOME IV
FACILITY NUMBER: 435200964

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building 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
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Based on observation, the licensee did not comply with the section cited above. LPA's observed two brown couches obstructing exit #3. Staff S2 stated the couches were placed in front of that exit by the morning staff because R1 likes to AWOL. LPA's observed a mattress, on the ramp directly next to the exit #4. LPA's observed the door to the outside (Exit #2) was obstructed by a black trash container. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. ADM stated she will send the written plan of action to LPA by POC date, August 22, 2024.
Type B
Section Cited
CCR
80075(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 record review, the licensee did not comply with the section cited above. While reviewing R3's medications, LPA observed medication #1 was not listed in R3's Centrally stored Medication Record. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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ADM stated she will conduct a medication training and send LPA documentation showing the training has taken place. ADM stated she will send the written plan of correction to LPA by POC date, August 22, 2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
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