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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201796
Report Date: 07/09/2024
Date Signed: 07/09/2024 04:12:35 PM

Document Has Been Signed on 07/09/2024 04:12 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/
DIRECTOR:		WEINSTEIN, MICHAELFACILITY TYPE:
735
ADDRESS:18225 HALE AVENUETELEPHONE:
(408) 465-8280
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 72CENSUS: 69DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Mark CastilloTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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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 Administrator, Mark Castillo.

LPA toured the facility with 2 staff to include resident bedrooms, bathrooms/shower rooms, activities rooms, patio, kitchen, and dining area.

Facility temperature maintained at 71 degrees Fahrenheit. All fire exits are free and clear of obstruction. LPA observed the patio door has an operable alarm. Fire extinguishers last serviced on 07/03/2024. Facility is equipped with dual smoke detectors and carbon monoxide detectors.

With the assistance of staff, LPA randomly entered into RM 115, 113, 111, 106, 204, 207, 213, 227, and 224. All bedrooms contained a bed, linen, adequate lighting, night stands, and a dresser and/or closet space.

Bathroom hot water temperature near room 109 maintained at 140 degrees Fahrenheit. Men's shower room hot water temperature maintained at 96 degrees Fahrenheit. During visit, the facility's maintenance personnel adjusted the hot water temperature throughout the facility. LPA observed the hot water temperature in the bathroom near room 109 is maintained at 109 degrees Fahrenheit and the men's shower room hot water is maintained at 92 degrees Fahrenheit. The women's shower room next to the men's shower room hot water temperature is maintained at 109 degrees Fahrenheit. Administrator was advised.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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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Document Has Been Signed on 07/09/2024 04:12 PM - It Cannot Be Edited


Created By: Christine Dolores On 07/09/2024 at 02:48 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: 07/09/2024

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 observation, interview, and record review the licensee did not comply with the section cited above in which 3 residents records were not complete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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Licensee will submit a statement of understanding of the section cited above along with the signed copies of R1, R3, and R4's forms which does not contain a signature.
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: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


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: 07/09/2024
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Kitchen equipped with plates, bowls, cups and utensils. Menu posted outside of the dining room area. Facility has at least 2 days worth of perishables and 7 days worth of non-perishables. Refrigerator temperatures maintained between 29 - 30 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. Items inside the refrigerator observed covered and labeled. Sharp objects observed in a secured area. Chemicals and disinfectants observed secured in a separate area where the kitchen equipment, utensils, and food are not stored.

LPA reviewed 6 resident files. 2 out of 6 resident's (R1 and R3) admission agreement, personal rights and consent forms are not signed by the resident and/or authorized representative. 1 out of 6 (R4) personal rights and consent form is not signed by the resident and/or authorized representative. During visit, Administrator was unable to produce the signed copies and was advised. The remainder of the resident files observed complete and maintained.

6 out of 6 residents centrally stored medications and centrally stored medication records were reviewed. LPA advised to ensure all resident's medications are accounted for in the CSMR. LPA advised to ensure all medications to include PRN medications has a start date. LPA reviewed 6 out of 6 resident's P&I funds with staff.

LPA reviewed 5 staff files were complete and maintained. LPA observed 2 staff has an active first aid certification.

Facility has an emergency disaster plan. Facility's last emergency drill was conducted in January 2024.

LPA obtained a copy of the LIC500.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Mark Castillo and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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