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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201681
Report Date: 12/06/2024
Date Signed: 12/06/2024 03:48:57 PM

Document Has Been Signed on 12/06/2024 03:48 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:LSA - HOME #2FACILITY NUMBER:
435201681
ADMINISTRATOR/
DIRECTOR:		CHERYLL LAGUNILLAFACILITY TYPE:
735
ADDRESS:830 AGNEW RDTELEPHONE:
(408) 988-9099
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 6CENSUS: 4DATE:
12/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Program Manager (PM) Felicia LehnerTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit as a subsequent visit conducted on 4/10/2024 on a death report for R1 wherein R1 passed away at the facility. LPA met with Program Manager (PM) Felicia Lehner and stated the purpose of today’s visit. LPA observed 3 staff and 3 residents at the facility and 1 resident is at the day program.

On 4/5/2024 at approximately 05:30am, staff (S1) conducted the routine wellness check on R1. S1 stated R1 was at his/her baseline, despite R1 not being responsive to any stimuli. S1 did not check on R1’s responsiveness, pulse, eye or skin abnormalities, sweating or high body temperature. S1 stated he/she was familiar with R1 and cared for R1 multiple times during nocturnal shift. R1 stated he/she would conduct activity check every 2-4 hours by observing R1 in the room, listening to R1’s breathing and check on R1’s incontinence needs. S1 stated he/she was not aware of any protocol or procedures for a client that appeared non-responsive.

At approximately 6:35am, staff (S1) asked incoming staff (S2) regarding R1’s baseline as response to S1’s assessment at 5:30am and R1 not being unresponsive. S2 observed R1 was unresponsive and called 911 for medical attention. The paramedics arrived and found R1 did not have a pulse and initiated CPR. The facility staff provided DNR order, and the paramedics stopped resuscitation efforts. The resident passed away due to natural causes as stated on R1’s Death Report.

Based on record review of facility’s policy on “Checking a Resident While They Are Sleeping”, if during staff’s check they notice a resident is in distress or displays any of the following symptoms, call 911 immediately which includes unresponsive, and resident cannot be aroused physically.

Continuation on LIC 809-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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 3
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: LSA - HOME #2
FACILITY NUMBER: 435201681
VISIT DATE: 12/06/2024
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Based on R1’s death certificate, the time interval is specified as “hours” where there is a gap from 5:30am when S1 observed R1 unresponsive to 6:25am when S2 observed R1 was still unresponsive. There was an approximately 1 hour gap from when S1 observed R1 unresponsive to when S1 called 911 for medical services.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Program Manager (PM) Felicia Lehner and a copy of the report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/06/2024 03:48 PM - It Cannot Be Edited


Created By: Simranjit Rai On 12/06/2024 at 02:04 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: LSA - HOME #2
FACILITY NUMBER: 435201681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2024
Section Cited
CCR
80075(a)

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80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services…including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidenced by:
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Program Manager stated to submit a written plan of action understanding regulation and ensure staff training is scheduled for all shifts routinely which includes facility's policy on “Checking a Resident While They Are Sleeping” by POC due date
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Based on interviews, S1 did not inform of his/her observation of R1 until S2 arrived at the facility, approximately 1 hour later. S2 assessed R1 wherein medical services is deemed necessary due to R1’s being unresponsive and cannot be physically aroused. S1 did not adhere to
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(cont') facility’s policy on “Checking a Resident While They Are Sleeping” for a resident that appeared non-responsive 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 Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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