435200996-2-13-2025-26-AS-KMAL-DDV4NF-20250213181505

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200996
Report Date: 02/13/2025
Date Signed: 02/13/2025 06:15:24 PM

Document Has Been Signed on 02/13/2025 06:15 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 LODGE		FACILITY NUMBER:	435200996
ADMINISTRATOR/ DIRECTOR:	MORALES, JAMES		FACILITY TYPE:	740
ADDRESS:	552 WEST HACIENDA AVENUE		TELEPHONE:	(408) 379-9331
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY: 30	TOTAL ENROLLED CHILDREN: 0	CENSUS: 17	DATE:	02/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Olivia Velasquez, Administrator Designee		TIME VISIT/ INSPECTION COMPLETED:	06:25 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	On February 13, 2025, at 12:45 PM, Licensing Program Analysts (LPA), Kenneth Madrigal and Manuel Monter, conducted an unannounced Required 1 - Year Visit. LPAs stated the purpose of the inspection visit and met with Staff 1 (S1) who contacted Olivia Velasquez, Administrator Designee (AD) and was granted entry to the facility. Olivia stated that “Judith Morales, the Administrator (ADM) is out of the country.” LPAs called Judith Morales on the phone, but ADM did not pick up the phone, so LPAs left a voicemail. AD stated there are 7 facility staff, and 17 residents present at the time of the visit. The facility has 16 resident rooms, 8 resident bathrooms, one dining room, two living rooms, one office, one kitchen area, one laundry area, one storage area, and 98 sprinklers. During today's visit, the LPAs toured the facility inside and out with AD. In the kitchen area, all the sharps and chemicals are locked and inaccessible to residents in care. In the kitchen area, a portion of the wall above the faucet and below the glass wood cabinet has exposed drywall. The facility room temperature is 75 degrees Fahrenheit. In the hallway leading to the storage room and perpendicular to the laundry room, there is a water leakage. (Photographs were taken.) In the bathroom between resident rooms 6 and 5, there are exposed wall. The bathroom between resident room 1 and two, S1 stated that there was plumbing issues. AD stated "the drain backed up happened this morning and the maintenance worker is resolving it." Across from the washer and dryer machine, there is a ceiling wall that is damaged. In bedroom #10, LPAs observed a container of Ultra Clean Detergent which the door of bedroom #10 was not locked and the door was open and was accessible to residents in care. S1 removed the detergent during the visit. LPAs observed the bathroom near resident room 15, the wall had stains and the ceiling fan had lint. LPAs observed the fridge perpendicular to resident room #6 had stains and ice buildup and observed food on the ground. See LIC 809C. Page 1 of 3.

Jackie Jin	TELEPHONE: (714) 319-3786
Kenneth Madrigal	TELEPHONE: (669) 660-1606
	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

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 6

Document Has Been Signed on 02/13/2025 06:15 PM - It Cannot Be Edited

Created By: Kenneth Madrigal On 02/13/2025 at 05:19 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: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations the licensee did not comply with the section cited above. LPAs observed laudnry detergent accessible in bedroom #10. LPAs observed tools accesible to residents in the backyard. LPAs observed storage shed window open with toxics and tools accesible via window. LPAs observed tools and detergent in second story staff area accesible to resident in care. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2025
	Plan of Correction
1 2 3 4	Staff removed toxics/detergents during visits. AD will send a Letter of Understanding regarding the regulation and the importance of ensuring that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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

TELEPHONE: (714) 319-3786

LICENSING EVALUATOR NAME:

Kenneth Madrigal

TELEPHONE: (669) 660-1606

LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 02/13/2025 06:15 PM - It Cannot Be Edited

Created By: Kenneth Madrigal On 02/13/2025 at 05:19 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: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. 3 out 4 staff health screeening forms were not signed by the phsyican. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/20/2025
	Plan of Correction
1 2 3 4	AD will submit a copy of all the 3, signed by the phsycian, staff health screening forms by POC due date.

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

TELEPHONE: (714) 319-3786

LICENSING EVALUATOR NAME:

Kenneth Madrigal

TELEPHONE: (669) 660-1606

LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 02/13/2025 06:15 PM - It Cannot Be Edited

Created By: Kenneth Madrigal On 02/13/2025 at 05:19 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: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

(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
1 2 3 4	Based on observation the licensee did not comply with the section cited above. Based on the totality of today's visit, LPAs observed a leaks in the facility, drywall missing in the facility bathroom, fridge's ice buildup perpenicular to room 6, wall above the kitchen facuet, screen doors obsevred not attached, backyard fence being propped by stick, LPAs noted other issues on report. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/20/2025
	Plan of Correction
1 2 3 4	AD stated that she will provide POC by the due date with detailed information in a document regarding the work plans for each individual issues found in today's visit. AD stated she will send photographs when they resolve these issues.

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPAs requested to review R1 to R4's Care Plans/Needs & Services Plan. AD stated the form was not completed. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/20/2025
	Plan of Correction
1 2 3 4	AD stated that she will provide all Care Plans for R1 to R4 and send LPA a copy. ADM will send by POC date.

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

TELEPHONE: (714) 319-3786

LICENSING EVALUATOR NAME:

Kenneth Madrigal

TELEPHONE: (669) 660-1606

LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

Page: 4 of 6

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: 02/13/2025

NARRATIVE

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While touring the backyard, LPAs observed directly next to the bedroom 16 exit outside, has a garden tool that is accessible to residents in care. LPAs observed a storage shed next to the gazebo which had a window opened with tools and chemicals when reaching the window. LPAs observed the wood fence being propped to prevent the fence from falling. In the outside premises, the exterior door of Room #12, the screen door is not attached. In the exterior, one of the wood handrails for the ramp for Room #3 is fragile and wiggles when used as support.

When entering the second story directly from the outside, LPAs observed in front of staff rooms, chemicals and tools are accessible to residents in care.

LPAs randomly tested three (3) resident bathrooms where the water temperature is recorded between 112 to 116 degrees Fahrenheit. In the living room, there were facility activities occurring for the residents such as music performance. Based on a review, the fire department conducted an inspection of for the sprinkler system which was in February 2024. The fire extinguisher was last serviced on January 8, 2025.

LPAs reviewed 4 Resident Records and 4 Staff Records. LPAs requested to review R1 to R4’s Appraisals Needs and Services. AD stated, “forms have not been filled out yet.” 3 out of 4 staff records did not have a signed Health Screening form by the Physician. LPAs also reviewed the Centrally Stored Medication and Destruction Record for 4 residents. LPAs reviewed facility disaster drill log, which stated January 25, 2025, was the last drill conducted. Additionally, LPAs audited the First Aid Kit, which has all the tools and equipment necessary for an emergency such as tweezers and scissors. LPAs requested a copy of the updated facility sketch plan.

See LIC 809 C. Page 2 of 3.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Kenneth Madrigal	TELEPHONE: (669) 660-1606
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: 02/13/2025

NARRATIVE

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Pursuant to California Code of Regulations (CCR), Title 22, Division 6, deficiencies are being cited during today's visit based on LPAs observations, please see LIC 809D.

The Department is issuing an immediate civil penalty of $250 for each repeat violation for the following deficiencies:
87303 Maintenance and Operation (a) was cited on February 22, 2024.

An Exit Interview was conducted with the Administrator Designee which includes the review of this Evaluation Report and a provided copy of this report to the Administrator Designee. Appeal Rights were provided to AD.

END OF REPORT. Page 3 of 3.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Kenneth Madrigal	TELEPHONE: (669) 660-1606
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

Page: 6 of 6