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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201959
Report Date: 07/03/2024
Date Signed: 07/03/2024 06:02:59 PM

Document Has Been Signed on 07/03/2024 06:02 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:CATHELEEN RCH-I & II DBA: CATHELEEN RCH IFACILITY NUMBER:
435201959
ADMINISTRATOR/
DIRECTOR:		GUADELIA FERRERFACILITY TYPE:
735
ADDRESS:1191 JANMARIE COURTTELEPHONE:
(408) 229-0845
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 4DATE:
07/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:10 PM
MET WITH:Administrator Hellen FerrerTIME VISIT/
INSPECTION COMPLETED:
06:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit in regards to an incident report the department received on May 20, 2024. LPA met with Administrator (ADM) Administrator (ADM) Hellen Ferrer and explained the purpose of the visit.

On May 20, 2024, the department received an incident report stating resident R1 handed a container of medications to his/her day program staff. A facility staff member went to the day program to investigate and retrieve the pills. The incident report states, the medications were in fact, R1's medications. Furthermore, the incident report states that the ADM conducted an investigation on regarding is incident and the staff who is assigned to help with medications at night was suspended for 3 days without pay.

On May 20, 2024, LPA Partoza interviewed ADM. ADM stated the staff gives the medication in a cup and give it to R1. ADM stated R1 usually eats in his/her room and the staff give the medication to him/her in the cup and R1 states he/she will take it, and the staff believe R1. ADM stated this usually happens at bed time at 7:00pm.

On July 3, 2024, LPA Monter interviewed ADM. ADM stated R1 likes to take his/her medication in his/her room. ADM stated the staff would give R1 his/her medication, but would not watch R1 take his/her medication.

Based on a review of R1's physicians report, dated May 14, 2024, R1 can not administer and store his/her own medications.
Based on a review of R1's IPP, dated November 10, 2021, "R1 needs assistance to take medications as prescribed."

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Hellen Ferrer and a copy of the signed report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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 07/03/2024 06:02 PM - It Cannot Be Edited


Created By: Manuel Monter On 07/03/2024 at 04:58 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: CATHELEEN RCH-I & II DBA: CATHELEEN RCH I
FACILITY NUMBER: 435201959

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/04/2024
Section Cited
CCR
80075(b)

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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement was not met as evidenced by;
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ADM stated she conducted a medication training for staff. ADM stated she will send documentation the training took place to LPA by POC date.
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Based on interviews conducted and records reviewed, facility staff did not ensure resident R1 take his/her medication as prescribed. This poses an immideate 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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024


LIC809 (FAS) - (06/04)
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