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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201523
Report Date: 01/30/2024
Date Signed: 01/30/2024 03:42:15 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/30/2024 03:42 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:
01/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Eleanore BasaTIME COMPLETED:
03:40 PM
NARRATIVE
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The purpose of this Case Management Visit is to amend the Annual Required Inspection on 1/25/24 wherein the Department discussed with lead staff (LS1) Sharon Basa the deficiencies found during the time of visit.

Due to time constraint LIC809-D was not issued. Today 1/30/2024, LIC809-D is being issued and an amended LIC809C page 2 of the Annual Required Visit. Copy of the amended LIC 809C and LIC 809D is provided.

On 1/25/24, LPA observed medications in bubble pack was in a plastic bag on the floor behind the couch. Staff (S1) stated that they received the bubble pack medications for 5 residents on 1/24/2024. There were approximately 2 grocery bags of medications (50 bubble packs, and 1 powdered medication bottle) that are accessible and not stored in a locked cabinet. During visit on 1/25/24 staff locked the medications.

Technical Advisories were also provided regarding fire extinguisher, the sliding door designated as an emergency exit in the staff room and the living area and staff are adhering to the disaster and casualty plan of the facility, perishable food and non-perishable supply and walkways in the backyard.

LPA conducted exit interview with ADM Eleanore Basa. Appeal Rights provided and a copy of this report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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 2
Document Has Been Signed on 01/30/2024 03:44 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/30/2024 03:42 PM


Created By: Maria Partoza On 01/30/2024 at 09:29 AM
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
CENTRAL COAST CR/RES, 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: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2024
Section Cited
CCR
80075(k)(1)

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(k)The following requirements shall apply to medications ... centrally stored (1) Medication ... kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision ... medication. This requirement is not met as evidence by:
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Based on observation and staff interview, 2 bags of residents' medication in bubble packs were observed unlocked behind the couch in the living room. Staff (S1) stated medications were received on 1/24/24 and did not secure the medications, which poses a health and safety risks to persons in care.
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
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