435201149-10-26-2023-26-AS-MMOR-CWYKVU-20231026081451

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201149
Report Date: 10/25/2023
Date Signed: 10/26/2023 08:15:03 AM

Document Has Been Signed on 10/26/2023 08:15 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:	BAYMILL CARE HOME II		FACILITY NUMBER:	435201149
ADMINISTRATOR:	LOLITA BAUTISTA		FACILITY TYPE:	735
ADDRESS:	2065 DANDERHALL WAY		TELEPHONE:	(408) 440-0433
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY: 6		CENSUS: 6	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrator Lolita Bautista		TIME COMPLETED:	02:10 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	Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Lolita Bautista . LPA toured the facility inside out with ADM which included; the Living room, kitchen, dining room, 2 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways. Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degree F, and hot water temperature was measured to range between 106-108 degrees F in both resident bathrooms. Fire extinguisher was serviced in 10/28/2022. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. ADM stated they have not conducted a drill Since July 2023. ADM stated her staff forgot to log in on the fire/earthquake log. LPA observed facility Fire disaster/earthquake drill log and a 2023 log is not in file. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff (S1 to S2). Residents were not interviewed because they were attending day program during LPA's visit. LPA reviewed 3 resident P & I records. Page 1 out of 2.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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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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: BAYMILL CARE HOME II	FACILITY NUMBER: 435201149
	VISIT DATE: 10/25/2023

NARRATIVE

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While auditing residents P & I records, LPA and ADM discovered that R1 was short 17 dollars. While reviewing R3's P & I records, LPA and ADM discovered that R3 had a surplus of 17 dollars. S1 stated he/she uses other residents money for change and forgot to reimburse R1. ADM stated they will review and make sure there is no discrepancies.

While reviewing residents medication records, LPA and ADM discovered R3 had the medication, vitamin D3, had been actively given but not logged in the MAR. ADM asked S1 if he/she forgot to sign. S1 stated he/she did give the medication, but forgot to sign on the MAR. LPA audited the medication for R3, medications have been given based on number of pills, start date, and remaining pill count.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Lolita Bautista. Appeal rights were provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/26/2023 08:15 AM - It Cannot Be Edited

Created By: Manuel Monter On 10/25/2023 at 01:52 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: BAYMILL CARE HOME II	FACILITY NUMBER: 435201149
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80070(b)(14)

Client Records

(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	While reviewing R1's P&I records, LPA and ADM discovered R1 was short 17 dollars. While reviewing R3's P & I records, LPA and ADM discovered that R3 had a surplus of 17 dollars. S1 stated he/she uses other residents money for change and forgot to reimburse R1. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2023
	Plan of Correction
1 2 3 4	ADM stated she will send plan of action on how she will keep the cash resources records up to date and correct. ADM stated she will send plan of action to LPA by POC date, 11/01/2023.

Type B

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA requested fire drill records. ADM stated a drill was conducted in July 2023. ADM stated the staff did not record the drill on the log. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2023
	Plan of Correction
1 2 3 4	ADM stated she will conduct a fire drill and send documentation to LPA by POC date, 11/01/2023.

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: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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