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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202529
Report Date: 07/29/2024
Date Signed: 07/31/2024 10:53:42 AM


Document Has Been Signed on 07/31/2024 10:53 AM - 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:MOSELLE CARE HOMEFACILITY NUMBER:
435202529
ADMINISTRATOR:MOHASSEL, LORIFACILITY TYPE:
740
ADDRESS:6797 MOSELLE DRIVETELEPHONE:
(408) 960-6279
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY:6CENSUS: 5DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Zenebesh GhebresallasieTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required 1 - year annual inspection. LPA met with Licensee, Zenebesh Ghebresallasie and Administrator (ADM) Lori Mohassel.

LPA toured the facility to include 5 resident bedrooms, 1 staff bedroom, bathrooms, kitchen, living room, dining room, garage, and backyard.

Facility temperature maintained at 72 degrees Fahrenheit. Fire extinguisher last serviced on 06/24/2024. Carbon monoxide detector present. All fire exit routes are free and clear of obstruction. 3 staff present are fingerprint cleared and associated to the facility.

Resident bedrooms equipped with beds, linens, adequate lighting, dressers, and night-stands. 4 out of 5 resident beds equipped with half bed rails. Bathroom hot water temperature observed to be originally maintained at 130 degrees Fahrenheit. During visit, Licensee adjusted the hot water temperature and LPA observed the hot water temperature is maintained at 112 degrees Fahrenheit. Shower is equipped with grab bars and shower chairs. Hygiene products observed secured.

Kitchen is supplied with at least 2 days worth of perishables and 7 days worth of non-perishables. Refrigerator temperature maintained at 30 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. Sharp objects, chemicals, disinfectants, and medications observed locked.

LPA reviewed 4 resident files. 4 out of 4 resident files contains an admission agreement, physician's report, TB result, pre-placement appraisal, functional capabilities assessment, appraisal/needs and services plan, weight record, identification and emergency contact information, personal rights, and consent form.

SEE LIC809-C.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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 4


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: MOSELLE CARE HOME
FACILITY NUMBER: 435202529
VISIT DATE: 07/29/2024
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LPA reviewed 4 resident's centrally stored medications and audited 4 resident's medications with the Licensee and ADM. It was observed that resident (R1)'s routine medication had 1 medication that is over by 5 tablets, 1 medication that is over by 4 tablets, and 1 medication that is missing 9 tablets. R1's Medication Administrator Record (MAR) shows that the medications were administered daily. Licensee was unable to determine where the discrepancies stemmed from. Resident (R3) had 1 medication that was missing 46 tablets. Licensee was unable to determine exactly where the discrepancy stemmed from but states they did not physically count the tablets in the medication bottle prior to starting the bottle of medication.

1 out of 4 resident's file did not contain a physician's order for half bed rails.

LPA interviewed 2 residents.

LPA reviewed 3 staff files. 3 out of 3 staff files contains a fingerprint clearance, 1st aid certification, health screening, and TB result. 3 out of 3 staff are provided annual training in topics to include but not limited to medication and dementia care.

Facility has an emergency disaster plan. LPA advised to update the emergency disaster plan using the updated LIC610E form. Facility conducts the emergency drills quarterly. LPA observed emergency lighting.

Posters observed in the facility to include but not limited to the licensing complaint poster, ombudsman poster, and personal rights.

The following documents were requested via email to include the updated Administrator Certificates for the ADM and Licensee, Liability Insurance, Emergency Disaster Plan, and LIC500.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Licensee, Zenebesh Ghebresallasie and Administrator (ADM) Lori Mohasse and a copy of the report was appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/31/2024 10:53 AM - 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: MOSELLE CARE HOME
FACILITY NUMBER: 435202529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87645(a)(4)
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review and observation the licensee did not ensure resident (R1) and (R2)’s medications were administered appropriately as the medication counts were not accurate. This poses an immediate health, safety, and personal rights risk to persons in care.
POC Due Date: 07/30/2024
Plan of Correction
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Licensee will submit a written plan when receiving and administering medications, and re-training for staff regarding medication administration. Licensee will submit the plan and training document to LPA Dolores via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/31/2024 10:53 AM - 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: MOSELLE CARE HOME
FACILITY NUMBER: 435202529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
(a) ... Postural supports may be used under the following conditions. (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
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Based on observation, interview, and record review the licensee did not ensure 1 resident had a physician's order on file for the use of half bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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Licensee requested for the resident's physician's order for half bed rails. Licensee will submit a statement of understanding of the section cited above and physician's order to LPA Dolores by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4