435202571-9-22-2023-26-AS-CDOS-CVWVWE-20230922164748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202571
Report Date: 09/22/2023
Date Signed: 09/22/2023 04:47:55 PM

Document Has Been Signed on 09/22/2023 04:47 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:	BELLEROSE SENIOR LIVING		FACILITY NUMBER:	435202571
ADMINISTRATOR:	LORI CORRAL		FACILITY TYPE:	740
ADDRESS:	100 BELLEROSE		TELEPHONE:	(888) 324-6520
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	26	CENSUS: 17	DATE:	09/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Lori Corral		TIME COMPLETED:	05:50 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) Christine Dolores arrived unannounced to conduct the facility's Required - 1 Year inspection. LPA met with Administrator (ADM), Lori Corral. During visit, LPA toured the facility with ADM to include the entrance, hallways, resident bedrooms, bathrooms, storage, shower rooms, kitchen, and exterior. All fire exit routes were free and clear of obstruction. Facility temperature maintained between 72 and 74 degrees Fahrenheit. Fire extinguisher last serviced on 08/31/2023. Carbon monoxide detector present in the facility. The main entrance is equipped with hand sanitizer, masks, and a lidded trash bin. Posters observed to include infectious disease prevention signs, visitation guidelines, facility license, personal rights, rights of resident council, evacuation plan, emergency phone numbers, if you see something say something, and ombudsman information. 13 out of 13 resident bedrooms contained beds, clean linens, adequate lighting, dresser, night stand, and chair. Shower room water temperature maintained at 122 degrees Fahrenheit. Suite #7 bathroom water temperature maintained at 116 degrees Fahrenheit. Kitchen observed with at least 2 days worth of perishables and at least 7 days worth of nonperishable foods. 2 out of 2 refrigerators temperature maintained at 39 degrees Fahrenheit. Freezer #1 temperature maintained at 0 degrees Fahrenheit. Freezer #2 temperature maintained at 15 degrees Fahrenheit. During visit, the facility's maintenance personnel began to repair the freezer. All foods were checked and re-located. LPA observed the activities calendar and menu was posted near the activity room and dining room. During visit, residents observed watching a movie in the dining room and participating in exercises in the activity room. SEE LIC809-C.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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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Document Has Been Signed on 09/22/2023 04:47 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: BELLEROSE SENIOR LIVING	FACILITY NUMBER: 435202571
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 ensure 3 out of 5 residents obstained a health screening report prior and after employment which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2023
	Plan of Correction
1 2 3 4	Licensee has secured a local clinic to perform the health screening for staff. Licensee will submit a scheduled date and time for each of the missing personnel to LPA Dolores by POC due date.

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 Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/22/2023 04:47 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: BELLEROSE SENIOR LIVING	FACILITY NUMBER: 435202571
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 ensure staff for each shift were provided quarterly drills which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Licensee will submit the signed in-service drill for each employee for each shift to LPA Dolores by POC due date.

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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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: BELLEROSE SENIOR LIVING	FACILITY NUMBER: 435202571
	VISIT DATE: 09/22/2023

NARRATIVE

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Facility has an updated emergency disaster plan. LPA observed the facility has multiple flashlights and batteries. First aid kit complete with bandages, tweezers, gauze, scissors, thermometer, and manual. Last fire drill was conducted on 09/2022. The facility has not completed quarterly fire drills with all staff per shift. Administrator was advised.

Facility has an updated infection control plan. LPA observed the facility has sufficient Personal Protective Equipment (PPE) supplies and a PPE storage bin which is readily available.

5 residents files were reviewed. 5 out of 5 residents included a signed admission agreement, medical assessment, TB, emergency information, appraisal/needs and services plan, personal rights, consent forms, safeguard of personal property and valuables, and centrally stored medication records.

5 staff files were reviewed. The facility has more than one person who obtains a 1st Aid certification. 3 out of 5 staff members did not have a health screening form on file. Administrator was advised. 5 out of 5 staff are fingerprint cleared and associated to the facility. 5 out of 5 staff were provided training on topics to include (but not limited to) resident personal care, special needs of the elderly, physical limitation, resident rights, medication, dementia care, emergency preparedness, housekeeping and sanitization protocols, postural support and special care, mandatory elder and dependent abuse, and incident reporting.

3 residents and 3 staff members were interviewed.

Documents were obtained during visit to include liability insurance and Administrator Certificate. An updated LIC500 was requested by the Administrator by Monday, 09/25/23.

Deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Lori Corral and Medication Technician Odalys Rodriguez and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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