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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200996
Report Date: 02/22/2024
Date Signed: 02/23/2024 10:35:50 AM

Document Has Been Signed on 02/23/2024 10:35 AM - 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: 20DATE:
02/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Randi CabreraTIME COMPLETED:
01:30 PM
NARRATIVE
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This is a continuation of the required annual inspection done on 2/14/2024. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced continuation visit for the required annual inspection and met with administrator/house manager (ADM/HM) Randi Cabrera.

Current census during today's visit is 20 residents 1 out of 20 is in rehabilitation, and 19 staff.
LPA observed that the kitchen has a commercial grade gas stove with griddle and range hood. LPA observed that the range hood accumulated grease and grime that could pose imminent danger to persons in care. A used paper towel was observed stuck between the vent hood and the cabinet on the top left side. A used paper towel was placed on the griddle left bottom corner (photos were taken).

Water temperatures for the bathroom and the kitchen was measured and ranges from 105 degrees Fahrenheit to 120 degrees Fahrenheit.

During inspection of the facility, LPA observed that the conference room had an accordion door, behind the accordion door are facility’s decorating supplies (Christmas decors), 2 oxygen tanks, some furniture, and unused wheelchairs. The items in the room obstructed a designated emergency exit door. LPA observed a recliner upon exiting the door from the conference room, which obstructs the access to the walkway.

LPA toured the residents’ and observed that emergency exits from the resident's room are clear from any obstructions, sliding doors are working and door alarms are in good working condition. LPA observed that residents’ rooms and common areas are clean and well maintained. All bathrooms have anti-skid mat and grab bars, sufficient supply of toilet rolls and paper towels. Resident rooms have ample storage, sufficient area for visiting families and clean beddings. Walkways inside the facility is clean and free from obstructions.

continued to page 2 LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PRINCESS LODGE
FACILITY NUMBER: 435200996
VISIT DATE: 02/22/2024
NARRATIVE
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Continued from Page 1 - LIC 809
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While inspecting the exterior perimeter and the backyard LPA observed a gazebo near the maintenance shed with tools that are in the open and can easily be accessed and poses imminent danger to persons in care. From the kitchen exit to the exterior, LPA observed a garbage dumpster, a wheel burrow and asphalt compactor obstructing the walkway and gate towards the front exterior of the facility and designated as an emergency exit,

LPA reviewed 5 resident records herein referred to as R1 to R5, and their centrally stored medication and destruction record (CSMDR). LPA observed that R1 has two expired medication that was not discarded and noted on the destruction record. R3 has medication that was not listed on the CSMDR.

LPA reviewed the 5 staff record, herein referred to as S1 to S5 and found training and personnel record updated.

The following deficiencies were cited based on the California Code of Regulations (CCR) Title 22. Deficiencies were observed on 2/14/2024 inspection and today's visit.
  • (87303)(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors .
  • 80087(d) Buildings and Grounds- All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
  • 87705 Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

continued to page 3 LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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: PRINCESS LODGE
FACILITY NUMBER: 435200996
VISIT DATE: 02/22/2024
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Deficiencies continued.
  • 87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (D)Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4). Any on-the-job training provided for the requirements in Section 87411(d)(4) may also count towards the requirement in this subsection.

An exit interview was conducted with administrator/house manager Randi Cabrera and a copy of this report and appeals right was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/23/2024 10:35 AM - It Cannot Be Edited


Created By: Maria Partoza On 02/22/2024 at 12:39 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: PRINCESS LODGE
FACILITY NUMBER: 435200996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
87303 (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors
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 observed accumulated grease and grime on the vent hood and used paper towel that was stuck in between the vent hood and the cabinet, and a paper towel left on the left corner of the griddle, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee stated that they will send a plan of correction (POC) by the due date and will have the vent hood cleaned and maintained and remind staff to report to administrator any maintenance concerns as soon as possible to ensure the health and safety of residents in care.
Type A
Section Cited
CCR
80087(d)
80087(d) Buildings and Grounds- 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 observed large items obstructing a designated emergency exit door in the conference room behind the accordion door, a large recliner seat by the exit doorway, large dumpster bin that was obstructing the gate and walkway designated for emergency exit and a wheel burrow containing asphalt, which poses an immediate health, safety or personal rights risk to persons in care
POC Due Date: 02/23/2024
Plan of Correction
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LIcensee stated that a plan of correction (POC) will be submitted to address obstruction from designated exits and walkways. Licensee stated they willl move the dumpster bin and make room in another area of the facility to store items that is currently blocking the emergency exit door in the conference room.
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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/23/2024 10:35 AM - It Cannot Be Edited


Created By: Maria Partoza On 02/22/2024 at 01:00 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: PRINCESS LODGE
FACILITY NUMBER: 435200996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 observed tools and paint sprays in the open inside the gazebo left unattended, which poses an immediate health, safety or personal rights risk to persons in care
POC Due Date: 02/23/2024
Plan of Correction
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Licensee stated that a plan of correction (POC) will be submitted on the due date and will remove the tools in the gazebo. Licensee stated that he/she will remind the maintenance person not to leave tools in the open unattended and when tools are not in use to keep it in a locked and inaccessible.
Type A
Section Cited
CCR
87411(c)(D)
87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (D)Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4). Any on-the-job training provided for the requirements in Section 87411(d)(4) may also count towards the requirement in this subsection. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above. Licensee did not discard and maintain record of expired medication R1 and R3 has a medication that was not prescribed in their centrally stored medication bin, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee stated he/she will send a plan of correction (POC) by due date. Licensee will conduct medication training to med techs to ensure proper documentation of medications received and needs to be discarded.
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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
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