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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201557
Report Date: 09/24/2024
Date Signed: 09/24/2024 01:09:49 PM


Document Has Been Signed on 09/24/2024 01:09 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:
09/24/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Lead Caregiver Staff Rose (Rosalia CalungcaginTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Marcela Yanez and Simi Rai conducted an unannounced Required 1 Year visit. LPAs met with Lead Caregiver (S1), Rose (Rosalia) Calungcagin and stated the purpose of today's visit. S1 notified Licensee/Administrator Leilani Cortes of LPAs' visit and S1 stated Licensee/Administrator was busy at the time and unable to be present during today's visit. LPAs observed 2 staff in the facility, 5 residents at the facility and 1 resident out of the facility. LPAs observed 3 cameras in common areas of the facility. S1 stated the cameras only record video and no audio.

LPAs observed 1 staff bedroom where in the door does not have locking capabilities. Staff S1 stated she resides in the staff room by herself. LPAs observed 7 day pill box on top of a table in staff room which was unlocked and accessible to residents in care . S1 stated the pill box belongs to her and the pill box contains prescription medication and vitamins. S1 removed the medication pill box and placed it in locked facility closet. LPAs observed office area which was converted to a living space for staff S2. LPAs observed a foldable mattress and S2's medication in a paper bag which were not locked and accessible to residents. S1 and S2 confirmed S2 is a live-in staff and sleeps at night in the office area 7 days out of the week.

LPAs toured the facility kitchen and observed food supply of at least 2 days of perishable food and 7 days of nonperishable food. LPAs at random inspected 10 canned foods and observed 2 cans of food and 2 yogurts cups that had expired. While touring the kitchen LPAs observed a small pill cup contained 2 medication tablets which was left unattended in the kitchen cabinet which did not have locking capabilities. LPAs also observed 2 knives and 1 multi-purpose scissors on the kitchen counter, hidden underneath a kitchen towel by S1, which was unlocked and accessible to residents in care. Fire extinguisher located in the kitchen was observed last serviced on 01/20/2024.

Continuation on LIC 809-C, Page 1 of 3.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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 7


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: 09/24/2024
NARRATIVE
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Page 2 of 3.

LPAs observed 4 resident bedrooms. LPAs observed resident R1 was laying in bed and LPAs observed the bed was attached with full bed rails. S1 stated R1 was not under Hospice Services at this time. LPAs observed 1 bottle of hydrogen peroxide in resident R3's bathroom cabinet unlocked and accessible located in R3's bedroom.

LPAs toured the garage and noted the door to the garage was unlocked during inspection. LPAs observed drawers in the garage, drawer which contained toxic chemicals such as Disinfecting wipes, Dishwasher Detergent and Spackle and tools such as Box Cutter Razor Blade, Hammer and Wrench. LPAs observed the garage drawer was unlocked and accessible to residents in care. Laundry area was observed laundry detergent was locked and inaccessible to residents.

During visit, LPAs toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPAs observed 1 shed which contained tools that were accessible to residents in care. The shed door was not locked and staff had placed a round brick to stop the door from opening. LPAs observed 1 locked shed used for storage space. Both sheds were used as storage space and not habitual space. LPAs observed a pool in the backyard with two gates door which were locked and inaccessible to residents. LPAs observed Chlorine tablets near the pool filter in an unlocked gated area. LPAs observed all windows and screens in good repair and working condition.

During inspection LPAs observed facility disaster drill which was conducted on 09/01/2024. LPAs inspected 3 bathrooms which all had non slip surface and grab bars in the showers. LPAs observed hot water temperature measured by thermometer which ranged from 108.9 - 109.2 degrees F. LPAs observed 1 prescription lotion, 3 ointment bottles and 1 multi-purpose scissors in the cabinet in Bathroom #1 which were unlocked and accessible to resident in care.

LPA Yanez reviewed and inspected resident files and medication at random for two residents and all medications were recorded on the Centrally Stored Medication Record. LPAs reviewed 2 staff files. LPAs observed staff S2 did not have Statement of Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders. Staff S1 confirmed S2 did not have the document in S2's file.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: 09/24/2024
NARRATIVE
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Page 3 of 3.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. Technical Violation was provided during today's visit. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Licensee/Administrator was not present during exit interview. This report was reviewed with Lead Caregiver (S1), Rose (Rosalia) Calungcagin and a copy of the report was provided. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/24/2024 01:09 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2024
Section Cited
CCR
87555(b)(8)

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87555 (b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
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Licensee/Administrator was not present during today's visit. Licensee/ Administrator to submit a written plan of action understanding regulation and will ensure all food stored at the facility is not expired and in-service training is scheduled by POC due date.
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Based on observation, Licensee did not ensure food stored at the facility were not expired wherein LPA Rai observed 4 out of 10 canned foods and packaged food were expired which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
09/25/2024
Section Cited
CCR87705(f)(1)

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
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Licensee/ Administrator was not present during today's visit. Administrator to submit a written plan of action understanding regulation and will ensure knives are stored inaccessible to residents and in-service training is scheduled by POC due date.
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Based on observation, Licensee did not ensure multiple knives were stored inaccessible to residents which LPAs observed in the kitchen, bathroom, garage and backyard which poses/posed an immediate Health, Safety, or Personal Rights risk 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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7


Document Has Been Signed on 09/24/2024 01:09 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2024
Section Cited
CCR
87705(f)(2)

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87705(f)(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol ... and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Licensee/ Administrator was not present during today's visit. Administrator to submit a written plan of action understanding regulation and will ensure over-the-counter medication, supplements/vitamins, toxic substances, gardening supplies were stored inaccessible to residents and in-service training is scheduled by POC due date.
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Based on observation, Licensee did not ensure over-the-counter medication, supplements/vitamins, toxic substances, gardening supplies were stored inaccessible to residents with Dementia in staff room, backyard, office and bathroom which poses/posed an immediate Health, Safety,
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(con't) or Personal Rights risk to persons in care.
Type A
09/25/2024
Section Cited
CCR87465(h)(2)

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87465 (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
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Administrator was not present during today's visit. Administrator to submit a written plan of action understanding regulation and will ensure centrally stored medicines shall be kept in a safe and locked place and in-service training is scheduled by POC due date.
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Based on observation, LPAs observed R1's medication was placed in small container in a cabinet which did not have locking capability which poses/posed an immediate Health, Safety, or Personal Rights risk 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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 09/24/2024 01:09 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2024
Section Cited
CCR
87202(a)

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87202 (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:
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Licensee/ Administrator was not present during today's visit. Administrator to submit a written plan of action understanding regulation and will ensure facility maintains fire clearance and create a plan to occupy the office as a living space for S2 by POC due date.
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Based on observation, LPAs observed a mattress and S2's medications in the office area. S1 and S2 stated S2 is a live-in staff and uses the office area as a bedroom which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
09/25/2024
Section Cited
CCR87608(a)(5)(B)

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87608 Postural Supports
(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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Licensee/ Administrator was not present during today's visit. Administrator to submit a written plan of action understanding regulation and to submit an exception request if R2 will continue to use a full bed rail by POC due date.
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Based on observation, LPAs observed resident R2 using a full bed rail and S1 confirmed R2 was not on hospice services which poses/posed an immediate Health, Safety, or Personal Rights risk 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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 09/24/2024 01:09 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2024
Section Cited
CCR
87412(a)

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87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.
This requirement was not met as evidenced by:
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Licensee/ Administrator was not present during today's visit. Administrator to submit a written plan of action understanding regulation and will ensure staff files are complete by POC due date.
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Based on record review, 1 out of 2 staff files was incomplete and did not contain Statement of Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders which poses/posed an potential Health, Safety, or Personal Rights risk 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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7