435201951-7-17-2024-26-AS-MPAA-D7A3HX-20240717181639

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201951
Report Date: 07/16/2024
Date Signed: 07/17/2024 06:18:08 PM

Document Has Been Signed on 07/17/2024 06:18 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:	PENDAR'S RESIDENTIAL CARE		FACILITY NUMBER:	435201951
ADMINISTRATOR:	MILA VALISTO		FACILITY TYPE:	740
ADDRESS:	515 TUSCARORA DR.		TELEPHONE:	(408) 784-3669
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 5	DATE:	07/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:46 PM
MET WITH:	Mila Valisto		TIME COMPLETED:	06:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/16/2024 at 1:00 p.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived and conducted an unannounced required 1 year inspection visit and met with Administrator (ADM), Mila Valisto. ADM contacted licensee, Marie Pendar, due to previous commitment was not able to stay in the facility. Licensee/ADM was in constant contact via phone with ADM. Licensee Marie Pendar arrived at the facility at around 6:20 p.m. LPA observed a ramp leading to the front door free from obstruction. The facility is a Residential Care Facility for the Elderly (RCFE) licensed to serve ages 60 and over 6 non-ambulatory, and a waiver for 2 hospice care. The facility's has 5 residents (R1 to R5) that have mild to advanced neurocognitive impairment. 4 staff were present including the ADM at the time of the visit. 5 residents were present at the facility. LPA observed 5 of 5 residents are in the bedroom. 2 of 5 are non-ambulatory and 3 of 5 are ambulatory. The facility has 5 resident room (BR2 to BR6) and 1 staff room (BR1). At 1:05 p.m. LPA toured the facility inside and outside with ADM, including but not limited to the kitchen, bathroom, dining room, living room, residents rooms, staff room, backyard and walkways. LPA observed the Personal Rights disclosure, Long Term Care Ombudsman (LTCO) prominently posted on the wall, visible to visitors, resident and staff. The temperature inside the home was at 73 degrees F. LPA and ADM toured the 5 bedrooms and LPA observed the rooms to be organized and free from debris and has sufficient storage for resident's personal belongings. 5 of 5 resident bedrooms have exit doors and are free from obstruction. 1 of 5 bedroom is shared by 2 residents. LPA observed 5 of 5 residents' bed are sanitary and free from debris. page 1 of 3 see LIC 809C

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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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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: PENDAR'S RESIDENTIAL CARE	FACILITY NUMBER: 435201951
	VISIT DATE: 07/16/2024

NARRATIVE

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LPA with ADM toured 3 full bathrooms (B1, B2 and B3). B1 is located at the hallway and shared by two resident. LPA observed B1 have non skid mats and grab bars and a bath seat with a broken leg that was tied together by a rope. B2 is used by one resident and has non-skid mats and grab bars. LPA observed that the trash bin inside B2 did not have a lid. B3 is located in a shared bedroom at the end of the hallway towards the back of the property. LPA observed that bath seat has water residue and soap residue.

LPA observed that the facility has a wall pull fire alarm system, a smoke alarm and a carbon monoxide alert system that is in good working condition. LPA observed night lights on the hallway. Hallways are free from obstruction. The sliding door going out to the back deck/patio slides easily and free from obstruction. LPA observed ramps and walkways are free from obstruction. LPA observed the backyard area to be free from debris and is maintained.

LPA tested the water temperature for kitchen and bathrooms, water temperature was measured at 105.9 degrees F. Dining and kitchen area and living room area were observed to be sanitary and organized. The facility has sufficient supply of perishable food for 2 days. The facility's non-perishable food for 7 days was not sufficient. The fire extinguisher located in the kitchen was last inspected on 1/12/2024.

LPA with ADM inspected the back exterior area of the facility. LPA observed that the ramps are free from obstruction, however wooden plank by BR2 sliding door entry way was frayed. LPA observed the screen door for BR3 was frayed. LPA observed the wooden plank on the ramp by BR6 was frayed and dipping when stepped on. LPA observed bed protectors on the clotheslines. The ramps rail were observed to be in good repair and sturdy.

LPA reviewed the following documents 3 of 5 resident record and 3 of 4 staff record. 1 of 3 resident have dementia, 1 of 3 has mild cognitive impairment. LPA observed that the following needs and services plan needs to be updated, 3 of 3 are missing signed consent form, 1 of 3 is missing the personal rights form.

LPA reviewed staff record and observed the following 3 of 3 staff record. 3 of 3 medical training is up to date 2 of 3 have the updated 1st aid cpr, 3 of 3 did not have a signed Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders (SOC 341A).

page 2 of 3 LIC 809C

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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: PENDAR'S RESIDENTIAL CARE	FACILITY NUMBER: 435201951
	VISIT DATE: 07/16/2024

NARRATIVE

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LPA reviewed 3 of 3 resident centrally stored medication record. Medications are properly labeled. LPA and ADM conducted medication review and observed that 3 of 3 resident have missing medication.

LPA requested the copy LIC 500, LIC 400, Updated Policy and Procedure, copy of the surety bond.

Deficiencies were cited during today's visit per California Code of Regulation Title 22. See LIC 809D. An Exit interview was conducted with administrator Mila Valisto and Licensee Marie Pendar.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 07/17/2024 06:18 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: PENDAR'S RESIDENTIAL CARE	FACILITY NUMBER: 435201951
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(d)(4)

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance. (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not correctly administer the medication for 3 out of 3 residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	Administrator stated that she is the one that administers the medications. Administrator will recount the medication as her plan and will create a better system to track the medication that are being administered or given to the residents. ADM stated that she will create the POC by the due date.

Type A

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not maintain the planks that was rotting and needs repair on the ramps of BR2 and BR5, the sliding door screen of BR2 was frayed and the bathroom shower chair has a broken leg and tied together by a rope, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	Licensee and ADM stated that they will submit a plan of correction to repair the rotting plank, the frayed screen and the shower chair will be replaced . LIC and ADM will submit the plan of correction by the 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: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 07/17/2024 06:18 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: PENDAR'S RESIDENTIAL CARE	FACILITY NUMBER: 435201951
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)(17)(A-F)

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (17) Documents and information required by the following: (A)Section 87457, Pre-Admission Appraisal;(B)Section 87459, Functional Capabilities;(C)Section 87461, Mental Condition;(D)Section 87462, Social Factors;(E)Section 87463, Reappraisals; and(F)Section 87505, Documentation and Support. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not maintain an updated record for 3 out of 3 resident's file that was reviewed during the time of inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	Administrator, stated that the record will be updated/completed by the POC due date. Adminstrator stated understanding of the requirement based on Title 22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

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