435202594-10-25-2023-26-AS-CDOS-CWXUWQ-20231025155708

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202594
Report Date: 10/25/2023
Date Signed: 10/25/2023 03:57:14 PM

Document Has Been Signed on 10/25/2023 03:57 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:	COMMUNITY SOLUTIONS CRISIS RESIDENTIAL		FACILITY NUMBER:	435202594
ADMINISTRATOR:	JENNIFER NGUYEN		FACILITY TYPE:	772
ADDRESS:	115 MADRONE AVENUE		TELEPHONE:	(669) 888-3182
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY: 15		CENSUS: 15	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Matthew Miao		TIME COMPLETED:	04:05 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 Program Manager (PM), Jennifer O'Leary, Program Supervisor (PS), Angelica Suud, and Program Director (PD) Matthew Miao. During visit LPA toured the facility with PM to include the entrance, living room, dining room, kitchen, resident bedrooms, bathrooms, office space, staff break room, laundry room, medication room, backyard, garage, and exterior. Facility temperature maintained at 68 degrees Fahrenheit. Fire extinguishers last serviced on 02/26/2023. Carbon monoxide and smoke detectors present in the hallways. At least two direct care staff were present, along with the program coordinator, therapist, supervisor, manager, and case manager. All staff present are fingerprint cleared and associated to the facility. In the dining room, LPA observed a wooden stick was blocking the opening of the sliding door leading to the front of the facility. The door has an alarm that was not turned on. PM immediately removed the wooden stick. LPA advised that the fire exit routes should be free and clear of obstruction at all time. Kitchen is supplied with cups, plates, bowls, and utensils. Facility has at least 2 days worth of perishable foods and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 35 degrees Fahrenheit. Freezer temperature maintained at -2 degrees Fahrenheit. Laundry room observed locked. The locked laundry room contained chemicals, disinfectants, and sharp objects. The laundry room also contained a few non-perishable foods which were placed in separate cabinets and counters than the chemical and disinfectants. Additional non-perishable foods were located in the garage to include PPE supplies and emergency food. SEE LIC812-C.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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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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: COMMUNITY SOLUTIONS CRISIS RESIDENTIAL	FACILITY NUMBER: 435202594
	VISIT DATE: 10/25/2023

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LPA observed rooms #1 - #5 with PM. Client bedrooms contains beds, linens, closet space, lighting, and a night stand for each client. Bathrooms observed clean and sanitary with no obvious foul odors or dirt marks. Hot water temperature in the bathroom maintained at 108 degrees Fahrenheit. Smoke detector observed in the hallway of each sleeping area in the facility.

Backyard observed with various activities, shade, tables and seating for the clients and visitors. No large bodies of water observed.

Facility has an updated emergency disaster plan. Emergency evacuation map posted throughout the facility. The facility's first aid kit observed with bandages, tweezers, scissors, gauze, and a manual. Staff and clients were provided quarterly emergency disaster drills. Facility has an infection control plan. LPA observed PPE supplies.

LPA reviewed 5 residents (R1 - R5) files to contain an admission agreement, medical assessment, TB result, appraisal/needs and services plan, emergency forms, safeguard of personal property and valuables, personal rights, consent forms, centrally stored medication records, and P&I money. LPA counted 5 residents medications with the facility's LVN. No issues were notes. LPA counted 3 out of 5 residents P&I money with PS and PD. 2 out of 5 residents did not have P&I money. No issues were noted.

LPA reviewed 5 staff files to contain a 1st aid certification, job application, health screening, TB results, and training records. 1 out of 5 staff did not have a health screening form on file. PD states they will work with their HR Department to send the staff (S1) out for a health screening.

5 residents and 5 staff were interviewed.

Documents were obtained to include the fire inspection results and service documentation regarding the facility's private source of water. PD will follow-up with LPA regarding the bacteriological analysis report.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Program Director, Matthew Miao and a copy of the report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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