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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201796
Report Date: 08/11/2023
Date Signed: 08/11/2023 04:02:26 PM

Document Has Been Signed on 08/11/2023 04:02 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:NUEVA VISTAFACILITY NUMBER:
435201796
ADMINISTRATOR:WEINSTEIN, MICHAELFACILITY TYPE:
735
ADDRESS:18225 HALE AVENUETELEPHONE:
(408) 465-8280
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 72CENSUS: DATE:
08/11/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Makel AliTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual continuation inspection. LPA met with Administrator Assistant (AA), Makel Ali.

During the initial annual inspection on 08/04/2023, LPA observed the men's and woman's shower room contain multiple black spots on the grout of the walls/ceiling and orange rust on the shower tiles. During today's visit, LPA observed the men's and women's shower room did not contain black spots on the grouts of the wall/ceiling and shower tiles were observed clean.

LPA entered the medication room to follow-up on concerns from the initial visit on 08/04/2023. On 08/04/2023, LPA and staff (S1) observed 5 residents centrally stored medication record (CSMR). LPA observed two of resident (R1)'s medications were not listed on the CSMR, did not include a start date on the record, the expiration date on the bottle was ineligible due to faded print, and the expiration date was not written on the CSMR. During today's visit, LPA encountered the same concern. Facility was advised.

LPA reviewed 5 out of 5 residents files. 5 out of 5 residents appraisal/needs and services plans were not signed by all parties. 5 out of 5 residents files includes an admission agreement, physician's report, TB result, emergency identification, personal rights, safeguard for personal properties and valuables, and safeguard for cash resources. The facility did not have an extra key to the file cabinet where the resident's secured P&I money was located because the responsible staff is currently on vacation. LPA was unable to inspect the residents P&I money during visit. Facility has a plan to ensure resident's are provided their P&I money throughout the week. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: NUEVA VISTA
FACILITY NUMBER: 435201796
VISIT DATE: 08/11/2023
NARRATIVE
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LPA reviewed 5 out of 5 staff files. 5 out of 5 staff files includes a 1st aid certification, personnel record, health screening, TB result, and employee rights. 5 out of 5 staff are fingerprint cleared and associated to the facility. 5 out of 5 staff were provided annual training on job related topics.

AA states staff were last provided an emergency drill in July 2023, however, was unable to locate the record during visit. Facility has an emergency disaster plan and procedures in case of an emergency.

Facility is equipped with Personal Protective Equipment (PPE) supplies to include gowns, shields, N95 masks, surgical masks, and gloves. Facility staff clean and disinfect multiple times daily and as needed. Staff were provided training on Personal Protective Equipment.

Facility has telephones located in the hallways for resident and staff use. Fireplace in the patio observed properly screened.

Facility freezer temperature maintained at -2 degrees Fahrenheit.

4 residents and 4 staff were interviewed.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. Advisory notes provided.

This report was reviewed with Administrator Assistant, Makel Ali and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/11/2023 04:02 PM - It Cannot Be Edited


Created By: Christine Dolores On 08/11/2023 at 01:57 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: NUEVA VISTA
FACILITY NUMBER: 435201796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, interview, and observation the licensee did not ensure 5 out of 5 residents appraisal/needs and services plans were signed and dated which poses a potential health, safety, and personal rights risk to persons in care
POC Due Date: 08/18/2023
Plan of Correction
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Licensee plans to re-review the appraisal/needs and services plan with the resident and/or resident's responsible party and to ensure the appraisal/needs and services plans are signed and dated. Licensee will send a written plan to LPA Dolores via email by POC due date.
Type B
Section Cited
CCR
80070(d)
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. ...

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 an extra key for the P&I funds was available therefore LPA was unable to inspect the residents P&I money which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee will copy an extra key for the P&I file cabinet. Licensee will send a picture of the key copy to LPA 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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 08/11/2023 04:02 PM - It Cannot Be Edited


Created By: Christine Dolores On 08/11/2023 at 02:01 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: NUEVA VISTA
FACILITY NUMBER: 435201796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

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 resident (R1)'s centrally stored medication record was maintained which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee will provide an in-service medication training to staff and coaching with medroom manager to ensure the training will be practiced. Licensee will submit the in-service training on medication for all staff to LPA 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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023


LIC809 (FAS) - (06/04)
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