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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201523
Report Date: 01/25/2023
Date Signed: 01/25/2023 02:39:09 PM

Document Has Been Signed on 01/25/2023 02:39 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:ELEANOR'S GLACIER 1 HOMEFACILITY NUMBER:
435201523
ADMINISTRATOR:ELEANOR BASAFACILITY TYPE:
735
ADDRESS:5863 TREETOP COURTTELEPHONE:
(408) 629-9183
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Eleanor BasaTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Licensee, Eleanor Basa and Administrator, Sharon Basa.

No clients observed on-site and were attending day program. During visit, LPA toured the facility to include the kitchen, living room, dining room, resident rooms, bathroom, garage, and backyard. All fire exit routes were free and clear of obstruction. Fire extinguisher last service date was 04/29/2022.

During tour, LPA observed 2 resident's (R1 - R2) bed contained full length bed rails with padding around the railings. LPA reviewed the facility file and did not observe exception requests were submitted to admit and retain a resident with full length bed rails. Licensee states an exception request was not submitted to the Department.

Facility has a designated entry point for verbal symptom screening, temperature check, and sign in for all visitors. Hand sanitizer and face masks made available at entry. LPA did not observe the facility's visitation guidelines posted. Facility staff clean and disinfect multiple times daily and as needed. Bathroom supplied with hand washing sign, paper supplies, hygiene products, and trash can with lid. Facility's staff training records were observed and did not indicate infection control training was conducted in 2022 - 2023. Licensee will ensure to train staff on infection control, ASAP. Staff are not N95 fit tested. Licensee states to work on getting staff N95 fit tested. LPA reviewed the facility's policies and procedures to isolation, testing for COVID-19, and visitation. The following posters observed to include lets keep facility clean, social distancing, and cough etiquette.

A deficiency was cited per California Code of Regulations, Title 22 and a plan of correction was developed with Licensee. See LIC809D. Advisory notes provided. This report was reviewed with Licensee, Eleanor Basa and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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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Document Has Been Signed on 01/25/2023 02:39 PM - It Cannot Be Edited


Created By: Christine Dolores On 01/25/2023 at 02:21 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: ELEANOR'S GLACIER 1 HOME
FACILITY NUMBER: 435201523

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(E)(1)
(E) Under no circumstances shall postural supports include tying of, or depriving or limiting the use of, a client's hands or feet. 1. ... Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on osbervation, record review, and interview the licensee did not ensure to submit an exception request for full length bed rails for 2 residents which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 02/23/2023
Plan of Correction
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Licensee will submit exception requests for 2 residents requesting to retain the residents with full length bed rails. Licensee will submit the exception requests to LPA 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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023


LIC809 (FAS) - (06/04)
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