435202594-9-30-2024-26-AS-CDOS-D9LT3X-20240930142303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202594
Report Date: 09/30/2024
Date Signed: 09/30/2024 02:23:11 PM

Document Has Been Signed on 09/30/2024 02:23 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/ DIRECTOR:	MATTHEW MIAO		FACILITY TYPE:	772
ADDRESS:	115 MADRONE AVENUE		TELEPHONE:	(669) 888-3182
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY: 15		CENSUS: 15	DATE:	09/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Angelica Suud		TIME VISIT/ INSPECTION COMPLETED:	02:25 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 annual inspection. LPA met with designated Administrator (ADM), Angelica Suud. LPA toured the facility with ADM to include the office rooms, hallways, living room, medication room, kitchen, dining room, laundry room, 5 resident bedrooms, bathrooms, and exterior. All fire exit routes are free and clear of obstruction. During visit, at least 2 staff members were observed on duty. Facility's temperature maintained at 71 degrees F. Smoke detectors and carbon monoxide detectors observed present. Fire extinguisher last serviced on 02/29/2024. Fireplace observed screened and blocked in the living room area. Kitchen supplied with at least 2 days worth of perishables and 7 days worth of non-perishable foods. LPA randomly opened the drawers and cabinets in the kitchen and did not observe sharp objects, chemicals or disinfectants that are easily accessible. Refrigerator temperature maintained at 35 degrees F and freezer temperature maintained at -4 degrees F. Laundry room that contained chemicals, disinfectants, and sharp objects observed locked. LPA observed the laundry room is equipped with non-perishable foods inside the cabinets. Chemicals and disinfectants are stored in separate cabinets than the food supplies. 5 resident bedrooms observed with beds, linens, closet space, and adequate lighting. Bathroom hot water temperature maintained between 108.5 - 109.2 degrees F. Bathrooms observed with non-slid floors. The bathroom shower next to room #6 observed with black grout between the shower tile. LPA advised to clean the grout to ensure there no mold for the health and safety of the clients. PAGE 1 OF 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

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: COMMUNITY SOLUTIONS CRISIS RESIDENTIAL	FACILITY NUMBER: 435202594
	VISIT DATE: 09/30/2024

NARRATIVE

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Medication room observed lock. Facility has a complete first aid kit. Sharp containers and PPE supplies observed. LPA reviewed 5 resident's centrally stored medications and centrally stored medication records. 5 out of 5 resident medications are completed and accounted for. LPA observed 1 resident's PRN medication was not part of the centrally stored medication record. LPA advised ADM to input the PRN medication on the centrally stored medication record according to the physician's order.

Garage supplied with additional perishable and non-perishable foods. Emergency supply box observed. Refrigerator temperatures maintained between 38 - 40 degrees F. Freezer temperatures maintained at 0 degrees F. 1 out of 2 storage units to the right of the garage observed to contain storage items. The beige storage unit was not inspected as ADM was unable to access that storage unit.

5 client records were reviewed to include an admissions agreement, consent forms, medical assessment, TB result, safeguard of personal properties, emergency contact information, and needs and services plan. 5 out of 5 client's needs and services plan did not contain a signature from the licensee and client or client's authorized representative. ADM states the facility is undergoing an update with their needs and services plan and the 5 client's were admitted during the transition period to their new form which is accessed electronically. LPA advised that the needs and services plan shall contain appropriate signatures. 5 out of 5 resident's P&I money was inspected and observed complete.

On 08/12/2024, Title 22 violations were observed during a DHCS annual inspection which was addressed during this annual inspection. During the DHCS review, 1 open client record contained a written assessment that did not include documented evidence that it was completed on admission and within the requirements of Title 9 Section 532.2(b). It was also observed that 1 open client record did not contain documented evidence that the treatment/rehabilitation review was prepared with staff and client at least weekly. PAGE 2 OF 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

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: 09/30/2024

NARRATIVE

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Based on interview with the ADM and record review, the facility corrected the deficiencies by meeting with the person responsible for performing admission assessments and reviewing the deficiencies. Going forward, they plan to conduct monthly audits to check that the updated mental health assessment form is being completed with all sections answers and signed, and treatment/rehabilitation plans are being reviewed and signed weekly with dates by both the client and staff member. Advisory notes provided.

5 staff files were reviewed. 5 out of 5 staff are fingerprint cleared and associated to the facility. LPA observed the staff files contains a job application, 1st Aid and CPR certification, health screening, and TB result. The facility's HR Department was unable to locate 1 staff member's health screening and TB result record. Staff states to have gotten the health screening and TB result upon hire. Staff will complete another TB result and health screening to retain on record. LPA reviewed 5 staff training records.

Facility has an emergency disaster plan. LPA advised to review and update the emergency disaster plan annually to ensure accuracy of the plan. Emergency drills are being conducted monthly. The last drill was completed on 09/24/2024.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with designated Administrator, Angelica Suud and a copy of the report and appeal rights was provided. PAGE 3 OF 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/30/2024 02:23 PM - It Cannot Be Edited

Created By: Christine Dolores On 09/30/2024 at 01:52 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: COMMUNITY SOLUTIONS CRISIS RESIDENTIAL	FACILITY NUMBER: 435202594
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81070(a)

(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. 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 comply with the section cited above in 5 out of 5 counts wherein 5 client's needs and services plan did not contain a visible signature from the client or client's authorized representative which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2024
	Plan of Correction
1 2 3 4	Licensee will submit a plan in writing to ensure all client's needs and sevices plans are appropriately signed to LPA Dolores via email by POC due date.

Type B

Section Cited

CCR

81066(c)(10)

(c) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 81065(g). 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 comply with the section cited above in 1 count wherein 1 staff member's file did not contain a health screening and TB result record which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2024
	Plan of Correction
1 2 3 4	Licensee will complete a health screening and TB test for the 1 staff member. Licensee will submit a statement of understanding of the section cited to LPA Dolores via email 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

LICENSING EVALUATOR NAME:

Christine Dolores

LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

LIC809 (FAS) - (06/04)

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