435202376-9-26-2024-26-AS-MPAA-D95VXV-20240915165009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202376
Report Date: 09/15/2024
Date Signed: 09/26/2024 05:42:00 PM

Document Has Been Signed on 09/26/2024 05:42 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/26/2024 03:11 PM

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

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 9/26/2024 - at 2:28 p.m. LPA Partoza conducted an unannounced visit to amend LIC 809C to add the PIN 19-01-CCLD Communication With Complainants and 809D to reflect the deficiency statement of *87355 (e)(1), obtain the signature which was both not captured during visit on 9/15/2024. On 9/15/2024 - at 2:45 p.m. LPA Partoza conducted an unannounced visit to amend the case management report to reflect the series of events and correct the citation that was issued at the time of the visit on 9/13/2024. At 3:45 p.m. LPA encountered a technical issue and have recreated this case management to correct the LIC 421BG. The previous LIC 421BG has the incorrect individual's name. In addition the LIC 809 D has the incorrect deficient statement and is missing a citation. On 9/13/2024, Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcella Tarin, conducted an unannounced case management - deficiency visit and met with licensees (LICs) Ramiro Custodio and Merclo Garcia and stated the purpose of the visit. On 9/13/2024, at 11:30 a.m. LPAs Partoza and Tarin interviewed the licensee and inquired about staff who are currently working at the facility. LIC stated that the facility currently has 5 staff and 1 out of 5 lives in the facility since July 1, 2024 and did not have a fingerprint/criminal record clearance. LIC stated that staff 1 (S1) is a family and helps with care and supervision of the residents such as but not limited to activity of daily living. At the time of the visit S1 was not present and was asked by the LIC to obtain a livescan. LIC stated that S1 have not been trained for the care and supervision of the resident which is a requirement for Residential Care Facility for the Elderly (RCFE) staff. page 1 of 2 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: 09/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2024

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: BONNEVIE RESIDENCE AND CARE	FACILITY NUMBER: 435202376
	VISIT DATE: 09/15/2024

NARRATIVE

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LPA discussed with LIC that S1 is required to have a fingerprint/criminal background clearance and be associated to the facility, prior to working, residing or volunteering. LPA informed LIC that S2 cannot work or be present in any community care facility unless he/she receives a criminal record clearance from the Care Provider Management Branch (CPMB). LPA discussed with LIC the importance of training staff prior to working with RCFE residents. LIC stated that they understand and will provide training to S1.

A deficiency was cited per California Code of Regulations, Title 22 87355 (e)(1) See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days x 1 individual = $500), for S1 that is residing at the facility without fingerprint and criminal background clearance. See LIC 421BG and for Title 22 87411 (c) Personnel requirement.

LPAs provided Licensee PIN 19-01-CCLD - Providers are prohibited by law from retaliating against anyone who submits a complaint to the Department or the State Long-Term Care Ombudsman. See California Health and Safety Code Sections 1539, 1568.07(d), 1569.37, 1596.857(b).

An exit interview was conducted during today's visit with licensee (LIC) Merclo Garcia. A copy of the report and appeals rights were provided

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end of report

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/26/2024 05:44 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/26/2024 02:56 PM

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: BONNEVIE RESIDENCE AND CARE	FACILITY NUMBER: 435202376
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/14/2024 Section Cited CCR 87355(e)(1)	1 2 3 4 5 6 7	87355 Criminal Record(e)All individuals...pursuant to Health and Safety Code Section 1569.17(b)... prior to working, residing ...in a licensed facility: (1)Obtain a California clearance ...as required by the Department. This requirement is not met as evidenced by: *deficiency stmnt did not print	1 2 3 4 5 6 7	LIC directed S1 to obtain a clearance during LPAs visit on 9/13/2024. LIC provided LPAs a copy of the livescan receipt. LIC stated as soon as S1 received the clearance from CPMB, LIC will associate S1 to the facility.
Type B 09/27/2024 Section Cited CCR 874111(c)	1 2 3 4 5 6 7	87411 Personnel Requirement General (c) All RCFE staff who assist residents ... shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement is not met as evidenced by	1 2 3 4 5 6 7	LIC stated that S1 will have an onboarding training and will not assist with resident's acitivities of daily living until fully trained. LIC stated that proof of training will be emailed to LPA by the end of the due date.
	8 9 10 11 12 13 14	Based on interview, LIC stated that S1 does not have training since residing in the facility 7/1/2024, and is current assisting with resident's with personal activties of daily living, which pose/poses a potential health, safety & personal rights risk to persons in care.	8 9 10 11 12 13 14	*87355 Criminal Record: Based on interview licensee did not obtain California criminal background clearance for S1 prior to residing and providing care & supervision since 7/1/2024, which poses/poses an immediate health, safety & personal right 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	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2024

LIC809 (FAS) - (06/04)

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