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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201626
Report Date: 06/24/2024
Date Signed: 06/24/2024 04:40:19 PM


Document Has Been Signed on 06/24/2024 04:40 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:WILLIE CARE HOMEFACILITY NUMBER:
435201626
ADMINISTRATOR:ZHAO,WUSHENGFACILITY TYPE:
740
ADDRESS:1194 SOUTH MARY AVE.TELEPHONE:
(408) 749-0823
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:6CENSUS: 6DATE:
06/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Guili XuTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Licensee Guili Xu and Administrator Wusheng Zhao.

During visit, LPA toured the facility with Licensee to include the resident bedrooms, staff bedrooms, living room, office, kitchen, garage, and backyard. LPA observed the sheds in the backyard contains storage items. All fire exits routes are free and clear of obstruction.
Facility temperature maintained at 76 degrees Fahrenheit. 3 staff and 1 live-in individual present are fingerprint cleared and associated to the facility. Facility has a carbon monoxide detector present. Fire extinguisher last serviced on 03/01/2024.

Kitchen observed with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 51 degrees Fahrenheit. Licensee was advised. Freezer temperature maintained below 0 degrees. Items inside the refrigerator observed covered. During visit, Administrator adjusted the temperature control of the refrigerator which will take about 24 hours to adjust. Fruits observed in the dining room. Sharp objects (such as kitchen knives), disinfectants, and chemicals observed secured inside the same cabinet in the kitchen. LPA advised to separate the chemicals and kitchen knives to avoid cross contamination. Licensee states they normally store the chemicals in a separate storage space. Administrator immediately moved the chemicals to another secured location. Medications observed locked.

Bathroom hot water temperature in the hallway maintained at 117 degrees Fahrenheit. The bathrooms contains accessible hygiene products. Based on review of resident records, 6 out of 6 resident's are not as risk if provided access to hygiene items.
SEE LIC812-C.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024
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 4


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: WILLIE CARE HOME
FACILITY NUMBER: 435201626
VISIT DATE: 06/24/2024
NARRATIVE
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LPA observed 6 resident rooms contained adequate lighting, a bed, chair, night-stand and dresser. 6 out of 6 resident beds observed with half bed rails. Licensee was unable to provide the physician's order for half bed rails for 6 residents. During visit, Licensee obtained a physician's order for half bed rails for 5 residents. Licensee was advised. 3 out of 6 residents are under hospice care. The facility only has an approved hospice care waiver for 2 residents. Licensee was advised.

LPA reviewed 6 resident records. Based on record review, 3 residents are noted to be bedridden. Licensee states 2 out of 3 resident's physician's report dated 06/13/2024 is incorrect and believes the residents are actually non-ambulatory. During visit, the Licensee contacted R1 and R4's doctor for clarification and obtained an order stating the 2 residents are non-ambulatory. Licensee was reminded of their approved fire clearance. Licensee states understanding. Licensee will ensure to update the resident's physician's report to reflect the correct ambulatory status. 6 out of 6 resident records contains an admission agreement, updated physician's report, TB result, updated appraisal/needs and services plan, consent forms, and personal rights.

LPA reviewed 2 staff records contained a fingerprint clearance, 1st aid certification, TB result, and employee rights. 1 out of 2 staff members was recently hired as of May 2024. Licensee states the new staff is provided training but licensee was unable to produce the completed training documentation. Licensee was advised to ensure the training documentation is filled out for new staff. Licensee stated understanding.

Facility has an emergency disaster plan. Flashlight, batteries and first aid kit observed. The last emergency drill was conducted on 03/15/2023. Licensee advised. LPA observed the facility has PPE supplies.

Documents were obtained to include Administrator Certificates and Liability Insurance. LPA requested Licensee to submit the LIC500, Emergency Disaster Plan, and Infection Control Plan by 06/25/2024.

Deficiencies were cited today per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Licensee Guili Xu and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/24/2024 04:40 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: WILLIE CARE HOME
FACILITY NUMBER: 435201626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (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, and record review the licensee did not comply with the section cited above where 6 out of 6 residents did not have a written order for half bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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During visit, Licensee obtained a written order for half bed rails for 5 out of 6 residents. Licensee will submit the written physician's order for the remainder of the 1 resident to LPA Dolores via email by POC due date.
Type B
Section Cited
CCR
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 notrequired 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
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Based on observation, interview and record review, the licensee did not ensure to conduct emergency drills quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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Licensee will submit a statement of understanding of the section cited above to LPA Dolores via email by POC due date.
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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/24/2024 04:40 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: WILLIE CARE HOME
FACILITY NUMBER: 435201626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(a)
(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. The request shall include, but not be limited to the following:

This requirement is not met as evidenced by:


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 ensure to request for a hospice waiver increase prior to retaining a resident under hospice care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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Licensee will submit a request to increase the facility's hospice care waiver to LPA Dolores via email 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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4