Community Care Licensing

SUPERVISOR'S NAME: Romeo Manzano TELEPHONE: (650) 388-2297 LICENSING EVALUATOR NAME: Manuel Monter TELEPHONE: (408) 712-2018 LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024

Document Has Been Signed on 08/02/2024 03:09 PM - It Cannot Be Edited

FACILITY NAME: DOMA CARE HOME	FACILITY NUMBER: 435202530
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2024

Type A

Section Cited

HSC

1569.32

Any duly authorized officer, employee, or agent of the department may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, this chapter. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. LPA's contacted facility Licensee requesting he/she come to the facility to let LPA's conduct annual inspection. Licensee stated she was busy and could not send anyone else to the facility to allow LPA's inside the facility. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2024
	Plan of Correction
1 2 3 4	Licensee stated he/she will send a written letter of understanding regarding the regulation. Licensee stated he/she will send the written plan of correction by POC date, August 3, 2024.

Type A

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA's observed several dead cockroaches inside and outside the facilty. LPA's observed rotting oranges and watermelon in the backyard of the facility. LPA's also smelled foul order inside and outside the facility. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2024
	Plan of Correction
1 2 3 4	Licensee stated he/she will send photot documentation showing all the dead cockroaches and rotting fruit has been removed to ensure the facility is clean, safe and sanitary at all times. Licensee stated he/she will send a written letter of understanding regarding the regulation. Licensee stated he/she will send the written plan of correction by POC date, August 3, 2024.

SUPERVISOR'S NAME: Romeo Manzano TELEPHONE: (408) 388-2297 LICENSING EVALUATOR NAME: Manuel Monter TELEPHONE: (408) 324-2112 LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024

Document Has Been Signed on 08/02/2024 03:09 PM - It Cannot Be Edited

FACILITY NAME: DOMA CARE HOME	FACILITY NUMBER: 435202530
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2024

Type A

Section Cited

CCR

87555(b)(28)

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA's observed serveral rotting foods inside the facility refrigerator such as spoiled fruit, salad and meat. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2024
	Plan of Correction
1 2 3 4	Licensee stated she will show photo documentation showing all spoiled food inside the refrigerator has been discarded. Licensee stated he/she will send a written letter of understanding regarding the regulation. Licensee stated he/she will send the written plan of correction by POC date, August 3, 2024.

Type A

Section Cited

CCR

87465(h)(2)

87465 Incidental Medical and Dental Care (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA's observed several medications which were not stored in a locked place, inacessible to persons other than employees responsible for the supervision of the centrally stored medication. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2024
	Plan of Correction
1 2 3 4	Licensee stated he/she will send a written letter of understanding regarding the regulation. Licensee stated he/she will send the written plan of correction by POC date, August 3, 2024.

SUPERVISOR'S NAME: Romeo Manzano TELEPHONE: (408) 388-2297 LICENSING EVALUATOR NAME: Manuel Monter TELEPHONE: (408) 324-2112 LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024

FACILITY NAME: DOMA CARE HOME	FACILITY NUMBER: 435202530
	VISIT DATE: 08/02/2024