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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202172
Report Date: 01/17/2024
Date Signed: 01/17/2024 02:44:00 PM

Document Has Been Signed on 01/17/2024 02:44 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:STURLA CARE HOMEFACILITY NUMBER:
435202172
ADMINISTRATOR:DUMANTAY, MARJORIEFACILITY TYPE:
735
ADDRESS:2644 STURLA DRTELEPHONE:
(408) 818-0134
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 5DATE:
01/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Marjorie DumantayTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Manuel Monter arrived at the facility unannounced to conduct a case management visit regarding a death report the department received pertaining to resident (R1). LPA met with Administrator, Administrator Marjorie Dumantay.

LPA also interviewed ADM, S1 and S2 regarding a death report that was received by the department on January 12, 2024, regarding resident, R1. R1's cause of death is still unknown.

ADM stated the resident was brought home December 3, 2023. ADM stated SARC came and did training for the catheter for staff. ADM stated home health was making two visits twice a week. ADM stated this was similar to an incident that occurred back in November. ADM stated the resident was showing similar symptoms. ADM stated R1 has not gone to the day program since November 2023. ADM stated she has restrictive health plan for R1, since December 3, 2023. ADM stated 4 staff completed the training. ADM stated the nurse came during the day, the wound nurse, at approximately 2:50pm. ADM stated she spoke with wound nurse at 3pm approximately, via phone. ADM stated the wound nurse recommended ADM make same day appointment with primary care physician, and if it wasn't possible, make emergency room visit, due to resident's failure to thrive, due to R1's wound not healing and his/her weight. ADM stated after phone call with wound nurse, she came to facility. ADM stated she called 911 at approximately 3:30pm.

LPA also requested the ADM send R1's documents to the department such as; Physician's Report, Needs and services plan, IPP, progress notes, Centrally stored medication records, facility restrictive health condition plan, weight records, MAR & staff schedule. ADM stated she would send R1's death certificate to the department once it become available.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Marjorie Dumantay and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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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