Community Care Licensing

Document Has Been Signed on 04/20/2023 04:48 PM - It Cannot Be Edited

FACILITY NAME:	HIDDEN LANE VILLA		FACILITY NUMBER:	435201306
ADMINISTRATOR:	THERESA CARR		FACILITY TYPE:	740
ADDRESS:	890 BERRY AVENUE		TELEPHONE:	(650) 254-0721
CITY:	LOS ALTOS	STATE: CA	ZIP CODE:	94024
CAPACITY: 6		CENSUS: 6	DATE:	04/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Valerie Santos		TIME COMPLETED:	05:00 PM

SUPERVISORS NAME: Romeo Manzano LICENSING EVALUATOR NAME: Ravi Patel LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023

Link to Parent Document Below:

FACILITY NAME: HIDDEN LANE VILLA	FACILITY NUMBER: 435201306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2023

Type B

Section Cited

CCR

87465(d)(3)

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of records, the licensee did not comply with the section cited above in 3 out of 6 resident Centrally Stored Medication Logs, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/27/2023
	Plan of Correction
1 2 3 4	Licensee agrees to create PRN medication logs for all residents with PRNs and submit copies of the logs to CCL by POC date.

Type B

Section Cited

HSC

1569.695(c)

(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in the facility file, which did not contain an Emergency Disaster Log, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/27/2023
	Plan of Correction
1 2 3 4	Licensee agrees to create an Emergency Disaster Log and conduct quarterly emergency disaster drills. The licensee shall submit a copy of the Emergency Disaster Drill Log to CCL by POC date.

SUPERVISOR'S NAME: Romeo Manzano LICENSING EVALUATOR NAME: Ravi Patel LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023

Link to Parent Document Below:

FACILITY NAME: HIDDEN LANE VILLA	FACILITY NUMBER: 435201306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2023

Type B

Section Cited

CCR

87465(h)(6)(A-F)

87465(h) The following requirements shall apply to medications which are centrally stored: 6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirement is not met as evidenced by: LPAs observed during review of residents R1-R6 that 6 out of 6 residents had medications that were not logged into the Centrally Stored Medication Record, which poses a potential safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4	Based on records review,, the licensee did not comply with the section cited above in 6 out of 6 Centrally Stored Medication Logs, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/27/2023
	Plan of Correction
1 2 3 4	Licensee agrees to audit all resident Centrally Stored Medication Logs and ensure that they are all complete. Licensee shall submit a Proof of Correction Letter by POC date ensuring that all resident Centrally Stored Medication Logs have been updated and completed. Licensee also agrees to train all staff on maintaining the Centrally Stored Medication Log and will submit training records to CCL by POC date.

SUPERVISOR'S NAME: Romeo Manzano LICENSING EVALUATOR NAME: Ravi Patel LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023

Link to Parent Document Below:

FACILITY NAME: HIDDEN LANE VILLA	FACILITY NUMBER: 435201306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2023

Type B

Section Cited

CCR

87705(c)(5)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of records, the licensee did not comply with the section cited above in 2 residents with dementia out of 6 resident Physician's Reports, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/27/2023
	Plan of Correction
1 2 3 4	Licensee agrees to schedule a doctor's appointment to obtain updated Physician's Reports for all residents with dementia and POC date and then submit copies of the updated Physicia's Reports to CCL once they are obtained.

Type B

Section Cited

CCR

87411(c)(1)

(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 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of records, the licensee did not comply with the section cited above in 1 out of 5 reviewed staff first aid certification records, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/27/2023
	Plan of Correction
1 2 3 4	Licensee agrees to obtain updated First Aid Certifications for all staff who currently have expired First Aid Certifications and submit the updated First Aid Certifications to CCL by POC date.

SUPERVISOR'S NAME: Romeo Manzano LICENSING EVALUATOR NAME: Ravi Patel LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023