435202571-9-11-2024-26-AS-CDOS-D8ZUFM-20240911153259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202571
Report Date: 09/11/2024
Date Signed: 09/11/2024 03:33:03 PM

Document Has Been Signed on 09/11/2024 03:33 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:	09/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Lori Carral		TIME COMPLETED:	03:35 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 annual required 1 - year inspection. LPA met with Administrator (ADM), Lori Corral. During visit, LPA toured the facility with ADM to include the kitchen, hallways, resident bedrooms, bathroom, shower room, storage closets, laundry room, medication room, and exterior. Fire exit routes were free and clear of obstruction. Exit doors equipped with operable door alarms. Facility staff present are fingerprint cleared and associated to the facility. Facility temperature maintained at 76 degrees F. Activities calendar posted outside of the activity room. Residents observed participating in activities to include movies, exercise, and live entertainment during visit. Kitchen observed with a lock on the door. Facility has at least 7 days worth of perishables and 2 days worth of non-perishable foods. Items inside the refrigerator observed covered and labeled. Refrigerator temperature maintained at 42 degrees F. Freezer temperature maintained at -3.5 degrees F. Cleaning solutions and food supplies observed in separate locations. Fire extinguishers last serviced on 09/01/2023 and 04/19/2024. Administrator states the fire inspector will be coming soon to service the extinguishers dated 09/01/2023. Facility has a carbon monoxide detector present. LPA and ADM entered into 4 resident bedrooms (#4, 9, 12, and 16). Resident bedrooms equipped with beds, linens, dressers, lidded trash bins, and adequate lighting. Sliding and screen doors are in working condition with no items obstructing the exit way. Showers observed with grab bars. Hot water temperature maintained between 116 - 118 degrees F. 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: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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: BELLEROSE SENIOR LIVING	FACILITY NUMBER: 435202571
	VISIT DATE: 09/11/2024

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LPA reviewed 4 resident files were complete to include an updated physician's report, needs and services plan, identification and emergency contact information, admission agreement, consent forms, personal rights forms, and safeguard of personal properties and valuables. 4 resident's beds are equipped with half rails and obtains a physician's order for the half bed rails. During the tour of the resident bedrooms, LPA observed hygiene items in 4 resident bedrooms. Based on record review of the resident's physician's report, 4 residents are not at risk if allowed access to hygiene items.

4 resident's centrally stored medications and centrally stored medication records were reviewed and observed complete. LPA observed expired PRN medication for 2 residents. LPA reviewed the PRN logs and 2 out of 2 resident's were not administered the expired PRN medications. Administrator immediately removed the expired medication and has plans for destruction.

LPA reviewed 4 staff files. 4 out of 4 staff files contains a health screening, TB result, 1st Aid and CPR certification, and personnel record. 4 out of 4 staff are fingerprint cleared and associated to the facility. 4 out of 4 staff were provided annual training to include not limited to: resident rights, medication, dementia care, emergency preparedness, housekeeping and sanitation, postural support and special care.

Facility has an updated emergency disaster plan. Emergency drills are completed quarterly. LPA observed emergency supplies to include first aid kits, flashlights, batteries, and non-perishable foods.

Facility has an infection control plan. LPA observed an adequate amount of PPE supplies in the storage closet. Facility has a stocked PPE cart and lidded trash bins available.

No deficiencies were cited today per California Code of Regulations, Title 22. This report was reviewed with Administrator, Lori Corral and MedTech, Odalys Rodriguez and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

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