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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200996
Report Date: 02/09/2023
Date Signed: 02/09/2023 12:00:15 PM


Document Has Been Signed on 02/09/2023 12:00 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:PRINCESS LODGEFACILITY NUMBER:
435200996
ADMINISTRATOR:MORALES, JAMESFACILITY TYPE:
740
ADDRESS:552 WEST HACIENDA AVENUETELEPHONE:
(408) 379-9331
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:30CENSUS: 22DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Kristine CabreraTIME COMPLETED:
12:05 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/03/2022 at 10:02am. LPA met with facility manager Kristine Cabrera (Admin).

LPA began touring the facility inside and out including reception are, kitchen, dining room, offices, 10 bathrooms, 10 bedrooms, outside perimeter, storage rooms, and med room. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

Facility Infectious Control plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. All restrooms were stocked with paper towels. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas.

Facility observed to have designated entry point. Staff took LPA's temperature, screened for symptoms, and recorded information in visitor log. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. 30 day supply of PPE observed. Fire Extinguishers observed to have been serviced on January of 2023. Carbon monoxide/smoke detectors were observed throughout the facility. Facility water temperature observed to be between 108.4*F and 150.2*F.

Deficiency cited during today's visit. This report was reviewed with facility manager Christine Cabrera and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
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 02/09/2023 12:00 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: PRINCESS LODGE
FACILITY NUMBER: 435200996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 - Maintenance and Operation - (e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). 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 due to sink in resident bathroom reaching a temperatue of 150.2 *F which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Licensee to adjust the water heater to the correct temperature and provide video documentation of sink outputting water at the correct temperature. If adjusting the water heater does not output water at acceptable levels, Licencee to provide proof of enlisted plumping services by 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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
LIC809 (FAS) - (06/04)
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