435202528-9-21-2023-26-AS-SRAI-CVVVWZ-20230921164846

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202528
Report Date: 09/21/2023
Date Signed: 09/21/2023 04:49:11 PM

Document Has Been Signed on 09/21/2023 04:49 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:	JULIETTE'S GARDENS (ROSE)		FACILITY NUMBER:	435202528
ADMINISTRATOR:	PEREZ, JONATHAN		FACILITY TYPE:	740
ADDRESS:	1511 ILIKAI AVE		TELEPHONE:	(408) 393-3882
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	6	CENSUS: 4	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Lead Caregiver, Lisa (Noveliza) Manzanilla		TIME COMPLETED:	05:00 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	Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Lead Caregiver, Lisa (Noveliza) Manzanilla and stated the purposed of today's visit. LPA Rai observed 2 staff in the facility, 3 residents sitting in living room. Lisa stated 1 resident is admitted to skilled nursing facility. LPA Rai spoke with Administrator (ADM) Jonathan Perez over the phone after completing inspection. LPA Rai observed 2 cameras in the facility. One camera is located in the office area of the dinning room facing the dining room and kitchen and another camera is located in the living room facing the resident's sitting area. ADM and S1 stated the cameras only record video and do not record audio. During visit, LPA Rai toured the inside and outside of the facility with Staff (S1). When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed the emergency exit ramp on the left side of the facility, when facing the facility building. This emergency exit ramp connects two resident rooms to the backyard. The concrete connecting the backyard floor to the wooden ramp is lifted approximately 3 inches, creating an uneven surface. S1 stated the residents have two additional emergency exits from the room. LPA Rai spoke with ADM and ADM is currently working with 2 contractors to fix the concrete in front of the wooden ramp. ADM stated the tree next to the concrete has lifted the concrete slab and the contractors will repair the concrete. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed secured areas for cleaning supplies and laundry detergents in the garage area. Continuation on LIC 809-C, Page 1 of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 10

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: JULIETTE'S GARDENS (ROSE)	FACILITY NUMBER: 435202528
	VISIT DATE: 09/21/2023

NARRATIVE

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During touring the resident rooms, 2 out of 3 resident beds had half side rails. LPA Rai reviewed resident records and 1 out of the 2 residents had a written order for the half side bed rails. LPA Rai reviewed R3's file and R3 did not have a written order from the physician for half side bed rails. LPA Rai observed camera inside the resident rooms facing the resident beds. LPA Rai spoke with the ADM and ADM stated the resident's families provided the baby monitors for night staff to oversee the resident's at night. ADM stated they can disconnect the cameras and notify the residents' families. LPA Rai observed the staff removing the cameras.

LPA Rai reviewed 3 out of 3 resident files. LPA Rai reviewed R1's file and R1 has a dementia diagnosis and did not have an updated Physician's Report, LIC 602A, and the document on file was signed on 3/8/2018. R1 did not have an updated Appraisal/ Needs and Services Plan and the document on file was signed on 3/16/2018.
LPA Rai reviewed R2's file and R2 has a dementia diagnosis and does not have an updated Physician's Report, LIC 602A, and the document on file was signed on 5/9/2022. R2 did have Appraisal/Needs and Services Plan dated 5/19/2022, but the document was not signed by Responsible Party nor Facility Representative. R2's file did not have an updated Appraisal Needs and Services Plan. R2's file did have an Admission Agreement document but the document was not filled out and it was not signed by Responsible Party or Facility Representative.
LPA Rai reviewed R3's file and R3 has a dementia diagnosis and R3 did not have updated Physician's Report, LIC 602A. R3's file did have an Appraisal/Needs and Services Plan document but it was not filled out with information and the document was not signed by Responsible Party and Facility Representative. R3's file did not have an updated Appraisal/Needs and Services Plan. R3's file did have blank Resident's Rights document and it was not signed by Responsible Party or Facility's Representative. R3's file did have blank Functional Capability Assessment and it was not signed by Responsible Party or Facility Representative. LPA Rai did review R3's Physician's Report which stated resident has auditory issues and R3 uses a hearing aid. R3's file did have blank LIC 9158 Telecommunications Devise Notification and it was not signed by Responsible Party and Facility Representative.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 10

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: JULIETTE'S GARDENS (ROSE)	FACILITY NUMBER: 435202528
	VISIT DATE: 09/21/2023

NARRATIVE

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LPA Rai reviewed resident medications and central stored medication records. LPA Rai and S1 counted the medications for R1. During a random review/audit of resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record. LPA Rai along with Staff (S1) counted the tablets from the medication bottles.
LPA Rai reviewed R1's Centrally Stored Medication Records with the stored medications. LPA Rai reviewed R1's medication and 4 out of 10 medications prescribed to R1 was not given as prescribed by the doctor. R1's medication #2 were counted 31.5 tablets instead of 32 tablets. S1 was not aware why one tablet was halved and R1 does not have an order for medication to be administered in a half. R1's medication #6 was counted at 260 tablets when there should be 258 tablets in the bottle. LPA Rai and S1 counted medication #6 three times and counted 260 tablets all three times. LPA Rai and S1 reviewed the facility's Medication Administration Record (MAR) and medication has been accounted for each dose since the bottle was opened. S1 stated the staff might have signed off the medication when the poured the medication in the medication cup and R1 may have refused the medication and the staff did not record the refusal on the R1's MAR. R1's medication #7 was counted at 72 tablets instead of 71 tablets, which concluded there were 1 tablet extra and resident was not administered one dose of the medication. LPA Rai and S1 reviewed R1's MAR which stated the first dose was taken on 4/8/2023, but the Centrally Stored Medication Log stated the prescription bottle was opened 4/6/2023. S1 stated R1 was given the medication starting 4/6/2023 and the MAR is incorrect, S1 stated there needs to be two signatures for 4/6/2023 and 4/7/2023 since S1 administered the medications both days. R1's medication #10 were counted 43 tablets instead of 39 tablets, which concluded there were 4 extra tablets and resident was not administered 4 doses of the medication and staff did not record the refusal on R1's MAR.

S1 stated R1's physician did not place any medications on hold and LPA Rai did not observe any MD orders in R1's file for a medication hold. S1 stated R1 was not admitted to the hospital or left the facility for long periods of time which would cause for resident to miss a dose of medication. S1 stated R1 did not refuse any medications according to R1's MAR.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 10

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: JULIETTE'S GARDENS (ROSE)	FACILITY NUMBER: 435202528
	VISIT DATE: 09/21/2023

NARRATIVE

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Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. One Technical Violation Note was provided during today's visit.

87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs.

LPA Rai spoke with Administrator (ADM) Jonathan Perez over the phone and went over today's report and deficiencies cited during today's visit. Administrator agreed and understood.

Exit interview was conducted with Lead Caregiver, Lisa (Noveliza) Manzanilla. A copy of this report was provided to Lead Caregiver, Lisa (Noveliza) Manzanilla. Appeal Rights were provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 4 of 10

Document Has Been Signed on 09/21/2023 04:49 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: JULIETTE'S GARDENS (ROSE)	FACILITY NUMBER: 435202528
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87457(c)(1)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents did not have Appraisal/Needs and Services Plan on file and 1 out of 3 residents did not have Functional Capabilities Assessment on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Administrator will complete Appriasal / Needs and Services Plan and Functional Capabilities Assessment with residents' POA and send to LPA by POC date. Licensee will provide a written plan for admission procdures for all new residents and will submit to LPA. Administrator agreed and understood.

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents did not have Admission Agreements signed by Responsible Party and Facility Representative which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Administrator will complete Admission Agreement with residents' POA and send to LPA by POC date. Licensee will provide a written plan for admission procdures for all new residents and will submit to LPA. Administrator agreed and understood.

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: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 5 of 10

Document Has Been Signed on 09/21/2023 04:49 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: JULIETTE'S GARDENS (ROSE)	FACILITY NUMBER: 435202528
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87698

87698 Postural Support (a) (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 comply with the section cited above in 1 out 3 residents had half-side bed rails attached to the bed without a written order from their physician which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Administrator will obtain a written order from a physician send to LPA by POC date. Licensee will provide a written plan to maintain resident's file and will submit to LPA. Administrator agreed and understood.

Type B

Section Cited

CCR

87705(c)(5)

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 3 residents with demenita diagnosis did not have an updated Phyician's Report, LIC 602A and updated appraisal/needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Administrator will submit a written plan on understanding regulations and procedures on annually updated documents for residents with Dementia and submit to LPA by POC date. Administrator agreed and understood.

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: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 6 of 10

Document Has Been Signed on 09/21/2023 04:49 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: JULIETTE'S GARDENS (ROSE)	FACILITY NUMBER: 435202528
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(b)

87507 Admission Agreements (b) The licensee shall complete and maintain in the resident's file a Telecommunications Device Notification form (LIC 9158, 11/04) for each resident whose pre-admission appraisal or medical assessment indicates he/she is deaf, hearing-impaired, or otherwise disabled in accordance with Public Utilities Code sections 2881(a) and (c). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 3 residents did not have a signed LIC 9158 document on file and medical assessment stated the R3 is hearing-imparied and wears a hearing aid which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Administrator will obtain a signed LIC 9158 form and send to LPA by POC date. Administrator will provide a written plan to maintain resident's file and will submit to LPA. Administrator agreed and understood.

Type B

Section Cited

CCR

00000

87468 Personal Rights (b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities or and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A)The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review,, the licensee did not comply with the section cited above in 1 out of 3 residents did not have a signed copy of Personal Rights of Residents on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Administrator will obtain a signed Personal Rights of Residents and send to LPA by POC date. Administrator will provide a written plan to maintain resident's file and will submit to LPA. Administrator agreed and understood.

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: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 7 of 10

Document Has Been Signed on 09/21/2023 04:49 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: JULIETTE'S GARDENS (ROSE)	FACILITY NUMBER: 435202528
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87307(a)

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 3 resident rooms had cameras facing the resident's bed and resident file did not have consent forms, updated Plan of Operations, or facility waiver for video surveillance in the private areas which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Administrator instructed the staff to remove the cameras in the residents room during today's visit. Administrator does not want to continue with video surveillance in the private areas. Administrator will inform the residents' responsible party. LPA Rai observed the staff removing the cameras from the resident rooms.

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: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 8 of 10

Document Has Been Signed on 09/21/2023 04:49 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: JULIETTE'S GARDENS (ROSE)	FACILITY NUMBER: 435202528
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(a)

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, interview and observation R1's 4 out of 10 medications not administered to R1 as prescribed by the physician which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Administrator will submit a written plan on understanding regulations and schedule in-services and training to staff by POC date. Administrator agreed and understood.

Type A

Section Cited

CCR

87207

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, interview and observation, R1's medications were counted during today's visit, the tablets/capsules in the prescription bottle did not match the doses given R1 based on the Medication Administration Record (MAR). This concludes the facility staff noted doses were given to R1 when medication was not adminstered, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Administrator will submit a written plan on understanding regulations and schedule in-services and training to staff by POC date. Administrator agreed and understood.

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: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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