435202557-10-18-2024-26-AS-MTAN-DA6RTP-20241018131840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202557
Report Date: 10/18/2024
Date Signed: 10/18/2024 01:18:57 PM

Document Has Been Signed on 10/18/2024 01:18 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:	BED OF ROSES RESIDENTIAL CARE HOME		FACILITY NUMBER:	435202557
ADMINISTRATOR:	WILLIAMS, MARIA CHRISTINA		FACILITY TYPE:	740
ADDRESS:	1730 WHITE OAKS ROAD		TELEPHONE:	(408) 603-7598
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	6	CENSUS: 4	DATE:	10/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Licensee, Christina Williams		TIME COMPLETED:	01:15 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) Marcella Tarin and Licensing Program Manager Jackie Jin conducted an unannounced annual inspection visit at 9:45AM and met with Licensee Christina Williams. LPA and LPM toured the facility inside and out with the Licensee to include the living room, dining room, kitchen, resident bedrooms, bathrooms, and exterior. All emergency exits were observed to be clear of obstruction. LPA and LPM toured the kitchen area and observed two residents sitting at the kitchen table eating breakfast at 9:45AM. LPA and LPM observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature maintained at 39.7 degrees F and freezer maintained at -8 degrees F. LPA and LPM observed toxins, sharps and chemicals locked and inaccessible to residents. LPA and LPM toured 4 resident bedrooms. 4 out of 4 resident bedrooms had beds, a dresser, functioning lights, storage space for personal belongings, clean bedding, and a chair. LPA measured hot water temperature, range of 109.9 to 118 degrees F for 2 out of 2 resident bathrooms. The facility was equipped with smoke and carbon monoxide detectors. Fire extinguishers were last serviced on 10/9/2023 and LPA observed extinguisher to be fully charged. LPA observed the facility first aid kit, and it was observed to be complete. The facility fire/earthquake drill log was reviewed, and drills are being conducted quarterly. The last fire drill was conducted on 07/05/2024. Facility has emergency disaster plan. LPA and LPM reviewed 4 residents Centrally Stored Medication and Destruction Records (CSMDR). LPA observed 4 out of 4 CSMDRs are complete with all medications accounted and documented. LPA and LPM observed the medication storage area was locked and inaccessible to residents in care.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

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: BED OF ROSES RESIDENTIAL CARE HOME	FACILITY NUMBER: 435202557
	VISIT DATE: 10/18/2024

NARRATIVE

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LPA and LPM reviewed 4 out of 4 resident records. LPA and LPM observed 4 out of 4 resident records to contain identification and emergency contact information, personal rights, TB results and consent forms. Residents (R2 and R4) records did not contain completed appraisal/needs and services plans. LPA advised Licensee to complete appraisal/needs and services plans. Residents R1 and R3 appraisal needs and service plan was not updated within the year. R1 and R3 have neurocognitive disorder.

LPA reviewed 4 out of 4 staff records. LPA observed 4 out of 4 records as complete to include fingerprint clearance, health screening, TB result, personnel record, and staff training.

Licensee Administrator Certification is current and expires on 11/26/2025.

A deficiency was cited today per California Code of Regulations, Title 22. A Technical Violation was issued today. See LIC809D. Exit interview was conducted with Licensee Christina Williams. This report was provided to Licensee and appeals rights were provided.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2024 01:18 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: BED OF ROSES RESIDENTIAL CARE HOME	FACILITY NUMBER: 435202557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

(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 observation and record review, the licensee did not comply with the section cited above. 1 out 1 residents did not have annual medical assessment. 2 out of 2 residents did not have a reappraisal completed within the year which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2024
	Plan of Correction
1 2 3 4	Licensee states she will complete the appraisal/needs and services plans for the two residents within the next two weeks. Licensee states she will obtain a medical assessment for R3 by November 1st, 2024. Licensee agreed to submit the appraisal/needs and services plan and medical assessment by POC due date November 1st, 2024 .

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: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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