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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201557
Report Date: 09/20/2023
Date Signed: 09/20/2023 07:07:43 PM

Document Has Been Signed on 09/20/2023 07:07 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:PRUNERIDGE RESIDENTIAL CARE HOMEFACILITY NUMBER:
435201557
ADMINISTRATOR:CORTES, LEILANIFACILITY TYPE:
740
ADDRESS:3030 PRUNERIDGE AVENUETELEPHONE:
(408) 247-2771
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 6CENSUS: 6DATE:
09/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lead Caregiver, Rose (Rosalia) CalungcaginTIME COMPLETED:
07:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Lead Caregiver (LC), Rose (Rosalia) Calungcagin and stated the purposed of today's visit. LC could not get a hold of Licensee Leilani Cortes and left a message. LPA Rai observed 3 staff in the facility, 4 residents sitting in living room, 1 resident sitting in the dining room, and 1 resident in the resident room.

LPA Rai observed 3 cameras in the facility. One camera is located in the living room, one camera is located in the dining room and one camera is located in the kitchen S1 stated the cameras only record video and no audio.

During visit, LPA Rai toured the inside and outside of the facility with Staff (S1). When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food. LPA Rai did not observe at least 7 days of nonperishable food. LPA Rai observed approximately 20 canned foods and approximately 5 boxes of various flour. LPA Rai observed an emergency food supply in the living room next to the TV, but the food supply box was open LPA Rai could not verify if the recorded pouches of food in the box were the correct number of pouches inside the box. Licensee (LC) Leilani Cortes stated she will follow up with the staff to ensure the emergency food supply box stays closed and ensure the facility maintains one week worth of non perishable foods which will be sufficient for 3 meals and 3 snacks for 6 residents for one week.

Sharps and medications were locked in secured areas. LPA observed secured areas for cleaning supplies and laundry detergents in the garage area. LPA Rai observed a podium in the garage and LC clarified they do not use the podium and the garage area is used as activity room for the residents. LPA Rai observed swimming pool in the backyard is fenced and inaccessible to the residents.

Continuation on LIC 809-C, Page 1 of 4.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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 12
Document Has Been Signed on 09/20/2023 07:07 PM - It Cannot Be Edited


Created By: Simranjit Rai On 09/20/2023 at 04:21 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: PRUNERIDGE RESIDENTIAL CARE HOME
FACILITY NUMBER: 435201557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
87555 General Food Service Requirements
(b)(26)Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in facility did not maintain one week of non perishable supplies and LPA Rai observed (count) canned fruits and vegetables which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator will submit a written plan of action and understanding of the regulation by POC date. Administrator agreed and understood.
Type A
Section Cited
CCR
87411(a)
87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, interview and observation R2's 4 out of 7 meds not administered to R2 as prescribed by the MD which poses an immediate Health, Safety, or Personal Rights risk to persons in care..
POC Due Date: 09/21/2023
Plan of Correction
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Executive Director submit a written plan on understanding regulations and schedule in-services and training to staff by POC date. Licensee agreed and understood.
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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


LIC809 (FAS) - (06/04)
Page: 2 of 12
Document Has Been Signed on 09/20/2023 07:07 PM - It Cannot Be Edited


Created By: Simranjit Rai On 09/20/2023 at 04:28 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: PRUNERIDGE RESIDENTIAL CARE HOME
FACILITY NUMBER: 435201557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87698(a)(3)
87698 Postural Support

(a) (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 6 out of 6 residents who are not on Hospice Services use half-side rails on bed and do not have written order from physician on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
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Licensee will submit a written plan of action and understanding of regulations by POC date. Licensee agreed and understood.
Type B
Section Cited
CCR
87457(c)
87457 Pre Admission Appraisal- General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above when out 3 of 6 resident files did not contain needs and services plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
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Licensee will complete appriasal / needs and services plan with residents POA and send to LPA by POC date. Licensee will provide a written plan for admission procdures for all new residents and will submit to LPA. Licensee agreed and understood.
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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 09/20/2023 07:07 PM - It Cannot Be Edited


Created By: Simranjit Rai On 09/20/2023 at 04:46 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: PRUNERIDGE RESIDENTIAL CARE HOME
FACILITY NUMBER: 435201557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 resident did not have a Physician's Report in resident's file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
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Licensee will complete Physician's Report with residents POA and send to LPA by POC date. Licensee will provide a written plan for obtaining medical assessments and keeping on file for all residents and will submit to LPA. Licensee agreed and understood.
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia
(c)(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
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Based on record review, the licensee did not comply with the section cited above in 4 out of 6 residents did not have annual medical assessment and 3 out of 6 residents did not have reappraisal completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
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Licensee will complete annual reappraisals/ medical assessments with residents POA and send to LPA by POC date. Licensee will provide a written plan to ensure maintainance of records for residents with dementia and will submit to LPA. Licensee agreed and understood.
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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 09/20/2023 07:07 PM - It Cannot Be Edited


Created By: Simranjit Rai On 09/20/2023 at 05:18 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: PRUNERIDGE RESIDENTIAL CARE HOME
FACILITY NUMBER: 435201557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(i)
87465 Incidential Medical and Dental Care
(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 medications for R2 were expired in the medication box and not recorded in the medication dustruction log and still in the bubble pack container which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
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Licensee will provide a written plan to ensure maintainance of medications and aditiional training on facility's process to dispose of medication by POC date. Licensee agreed and understood.
Type B
Section Cited
CCR
87466
87466 Observation of the Resident

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of the 2 residents did not have record of weight log in file. R3 was weighed during visit and R6 is bedridden and other means of measurement was not recorded which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
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Licensee will provide a written plan of action and understanding of regulations by POC date. Licensee agreed and understood.
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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 09/20/2023 07:07 PM - It Cannot Be Edited


Created By: Simranjit Rai On 09/20/2023 at 05:33 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: PRUNERIDGE RESIDENTIAL CARE HOME
FACILITY NUMBER: 435201557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87615(a)(5)
87615 Prohibited Conditions
(5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 6 resident requires total care which includes resident not able to reposition in bed without assistance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
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Licensee will provide a written plan of action and understanding of regulations by POC date. Licensee agreed and understood.
Type A
Section Cited
CCR
87618(a)(2)
87618 Oxygen Administration - Gas and Liquid
(a) Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who requires the use of oxygen gas administration under the following circumstances:
(2) If intermittent oxygen administration is performed by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 6 resident requires the use of oxygen and resident was discharged from Hospice on 9/19/2023 and does not have home health services which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
1
2
3
4
Licensee will submit a written plan of action and understanding of regulations by POC date. Licensee agreed and understood.
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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 09/20/2023 07:07 PM - It Cannot Be Edited


Created By: Simranjit Rai On 09/20/2023 at 05:42 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: PRUNERIDGE RESIDENTIAL CARE HOME
FACILITY NUMBER: 435201557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(c)(1)
87618 Oxygen Administration - Gas and Liquid
(c) The licensee shall be permitted to accept or retain a resident who requires the use of liquid oxygen under the following circumstances: (1) The licensee obtains prior approval from the licensing agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 6 resident not receiving home health or hospice services requires oxygen use does not have an approval on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Licensee will submit written plan of action and required documents for exception request for oxygen use for R6 by POC date. Licensee agreed and understood.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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2
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 09/20/2023 07:07 PM - It Cannot Be Edited


Created By: Simranjit Rai On 09/20/2023 at 05:45 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: PRUNERIDGE RESIDENTIAL CARE HOME
FACILITY NUMBER: 435201557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(b)(1)
87458 Medical Assessment
(b) The medical assessment shall include, but not be limited to (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents does not have TB test results in resident's file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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3
4
Licensee to submit a written plan of action to obtain TB test results for R3 by POC date. Licensee agreed and understood.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


LIC809 (FAS) - (06/04)
Page: 9 of 12
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: PRUNERIDGE RESIDENTIAL CARE HOME
FACILITY NUMBER: 435201557
VISIT DATE: 09/20/2023
NARRATIVE
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Page 2 of 4.

During tour of the resident rooms, LPA Rai observed 6 out of the 6 beds have half bed side rails. S1 stated residents do not receive Hospice services. LPA Rai reviewed 6 resident files and did not observe written order from a physician for half bed side rails.

LPA Rai observed oxygen tank in resident R6's room. S1 stated R6 is discharged from hospice services since yesterday 9/19/2023 and does not have home health services at this time. S1 stated R6 has dementia diagnosis and R6 is not mentally and physically capable of operating the equipment, R6 is not able to determine his/her need for oxygen, and R6 is not able to administer it him/herself. S1 stated R6 does not have an appropriately skilled professional performing oxygen administration. S1 stated R6 requires total care and R6 is bedridden not able to reposition his/herself in bed. LPA Rai notified S1 that total care is a prohibited condition and S1 stated R6 was on hospice services but was discharged from services yesterday 9/19/2023. S1 stated there are no assessments completed for R6 to go back to hospice services or initiate home health services.

The facility bathroom had available soap, paper towels, and trash cans with lids. The shower had grab bars and non-skid mats. The water temperature in the bathroom sinks ranged from 105.1F-106.5F. The water temperature in the kitchen sink was 105.3F. Facility smoke detectors and carbon monoxide detectors were in working condition. 4 out of 4 resident bedrooms had available bedding, drawers, and functioning lights.

LPA Rai reviewed facility records for 6 residents. LPA observed 3 residents did not have an appraisal/needs and services plan since their admission date. LPA Rai observed 1 resident did not have a medical assessment completed, such as the LIC 602A Physician's Report, since their admission date. LPA Rai observed 3 out of 6 residents with dementia diagnosis did not have annual needs and services plan, last needs and services plan on file was completed in 2020. LPA Rai observed 4 out of 6 residents with dementia diagnosis did not have annual medical assessment completed, such as the LIC 602A Physician's Report, last medical assessment on file was completed in 2019, 2020, and 2021. LPA Rai did not observe TB test results for R3 in resident's file.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC809 (FAS) - (06/04)
Page: 12 of 12
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: PRUNERIDGE RESIDENTIAL CARE HOME
FACILITY NUMBER: 435201557
VISIT DATE: 09/20/2023
NARRATIVE
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Page 3 of 4.

LPA Rai reviewed 4 of 6 resident's weight log. LPA Rai did not observed the weight record of R3 and R6. S1 stated R3 was recently admitted and did not have a weight log. Based on record review, R3 has been admitted to the facility for 3 months and did not have any recorded weight log. S1 and S3 weighed R3 during today's visit and initiated weight log. Based on LPA Rai's observation and S1's interview, R6 is bedridden was discharged from Hospice yesterday 9/19/2023. LPA Rai did not observe any Hospice notes or facility notes on resident's weight log. S1 stated Hospice sometimes measures R6's arm, but LPA Rai did not observe any progress notes mentioning resident's arm measurements. S1 could not located records with arm measurements. S1 could not locate a tape measurement in the facility.

LPA Rai reviewed resident medications and central stored medication records. LPA Rai and S1 counted the medications for R2 and R5. LPA Rai reviewed R2's and R5's Centrally Stored Medication Records with the stored medications. During a random review/audit of resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record, 4 out of 7 medications prescribed to R2 was not given as prescribed by the doctor. LPA Rai along with Staff (S1) counted the tablets from the medication bottles.
R2's medication #1 were counted 10 tablets instead of 0 tablets, since the medication bottle should have been empty if medication was administered according to the MD's prescription and order on the prescription bottle.R2's medication #2 were counted 140 tablets instead of 142, which concluded there were 2 medication pills missing from the prescription bottle. R2's medication #3 were counted 32 tablets instead of 34 tables, which concluded there were 2 medication pills missing from the prescription bottle. R2's medication #5 were counted 41 tablets, when there should have been 40 tablets, which concluded there were 1 tablets extra and resident was not given one dose of the medication.

S1 stated R2's physician did not place any medications on hold and LPA Rai did not observe any MD orders in R2's file for a medication hold. S1 stated R2 was not admitted to the hospital or left the facility for long periods of time which would cause for resident to miss a dose of medication. S1 stated R2 did not refuse any medications. S1 stated S1 is a live-in staff and S1 is the only staff member who administered the medications to the resident.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC809 (FAS) - (06/04)
Page: 10 of 12
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: PRUNERIDGE RESIDENTIAL CARE HOME
FACILITY NUMBER: 435201557
VISIT DATE: 09/20/2023
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Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs.

LPA Rai spoke with Licensee Leilani Cortes over the phone and went over today's report and deficiencies cited during today's visit. Administrator agreed and understood.

LPA Rai went over Administrator expectations of the administrator being present in the facility at least 20 hours a week. Licensee Leilani Cortes is the administrator of this facility.

Exit interview was conducted with Licensee, Leilani Cortes. A copy of this report was provided to Lead Caregiver, Rose (Rosalia) Calungcagin. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC809 (FAS) - (06/04)
Page: 11 of 12