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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200964
Report Date: 09/29/2021
Date Signed: 09/30/2021 02:58:14 PM

Document Has Been Signed on 09/30/2021 02:58 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:MERTZ CARE HOME IVFACILITY NUMBER:
435200964
ADMINISTRATOR:MERTZ, ELVIRAFACILITY TYPE:
735
ADDRESS:2591 BOREN DRIVETELEPHONE:
(408) 947-0825
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
09/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Malu MarquezTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA), Steve Nguyen, conducted an unannounced case management visit today and met with Administrator, Malu Marquez.

On 8/19/2021, Department received an incident report that resident (R1) eloped from the facility on 8/12/2021 and was returned to facility on same day at approximately 1PM. San Jose Police Department was contacted by facility; during call, 911 dispatch was able to located R1's location and R1 was able to return to facility.

On 8/19/2021, AD submitted copies of R1's Physician's Report (LIC 602A), Individual's Program Plan (IDP) and Appraisal/Needs and Services Plan (LIC 625) to LPA.

Today, 9/29/2021, LPA interviewed AD regarding the elopement of R1. AD stated that staff informed her that R1 had eloped. Per the review of R1's physician's report, R1 is unable to leave the facility unassisted.

A deficiency was cited during today’s tele-visit, see LIC809-D. Citation, Plan of Correction, and Appeal Rights were discussed with and a copy provided to Administrator Malu Marquez to review and sign.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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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Document Has Been Signed on 09/30/2021 02:58 PM - It Cannot Be Edited


Created By: Steve Nguyen On 09/29/2021 at 03:15 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: 09/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2021
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
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AD agreed to conduct training and submit an updated written plan of action on how to ensure the safety of residents with elopement history.
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This requirement was not met as evidence by: Based on interview and records review, R1 eloped from the facility without staff knowledge on 8/12/2021. This posed an immediate health and safety risk to resident in care.
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Addtionally, AD shall also schedule a meeting with Care Team to address R1's elopement behavior and submit to Department proof of scheduled meeting and provide meeting's agenda with a POC DUE DATE of 10/06/2021.

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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:Jackie Jin
LICENSING EVALUATOR NAME:Steve Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2021


LIC809 (FAS) - (06/04)
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