435202646-7-30-2024-26-AS-SRAI-D7NRLG-20240730130706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202646
Report Date: 07/30/2024
Date Signed: 07/30/2024 01:07:19 PM

Document Has Been Signed on 07/30/2024 01:07 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:	MAGDALENE RESIDENTIAL CARE		FACILITY NUMBER:	435202646
ADMINISTRATOR:	LITERATO-HILARIO, FE		FACILITY TYPE:	740
ADDRESS:	1109 E HOMESTEAD RD		TELEPHONE:	(408) 882-3926
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	6	CENSUS: 6	DATE:	07/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Lead Staff, Ellenelsa Lopez		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) Simi Rai conducted an unannounced Required 1 Year visit and met with Lead Staff, Ellenelsa Lopez and stated the purpose of today's visit. LPA Rai spoke with Administrator, Fe Literato-Hilario and stated the purpose of today's visit. LPA Rai observed 3 staff and 6 residents at the facility. All 3 of 3 staff were criminal record cleared and associated to the facility. During visit, LPA Rai toured the inside and outside of the facility. LPA Rai observed required posters hanging on the walls of the facility, near the front door and living room. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 4 storage sheds that was not used as habitual space. LPA Rai observed the fence shared with the facility on the right side facing the facility from the main street was being replaced and Lead Staff stated they supervise residents when using the backyard. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the facility bedrooms. 5 out of 9 bedrooms are being occupied by residents. Rooms had available bedding, drawers, and functioning lights. 4 Out of 9 bedrooms are being occupied by staff who are criminal record cleared and associated to the facility. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 112.5 degrees F - 114.5 degrees F. The water temperature in the kitchen sink was 108.1 degrees F. Continuation on LIC 809-C, Page 1 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

Document Has Been Signed on 07/30/2024 01:07 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: MAGDALENE RESIDENTIAL CARE	FACILITY NUMBER: 435202646
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)

87466 (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: 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 R1's Centrally Stored Medication Record/Log was not maintained since it did not contain information regarding medication #1 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2024
	Plan of Correction
1 2 3 4	Administrator stated to submit a written plan of action understanding regulation and will ensure in-service is conducted to address accurate record keeping of medications administered to resident by POC due date. Administrator agreed and understood.

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: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 07/30/2024 01:07 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: MAGDALENE RESIDENTIAL CARE	FACILITY NUMBER: 435202646
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in staff file did not contain updated first aid training certification for staff S1 who provides residents assistance with ADLs which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2024
	Plan of Correction
1 2 3 4	Administrator stated to submit a written plan of action understanding regulation and will ensure all staff providing assistance with ADLs have valid first aid training certification by POC due date. Administrator agreed and understood. Administrator stated S1 will be scheduled today 7/30/2024 to receive first aid training.

Type B

Section Cited

CCR

87608(a)(3)

87608(a)(3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 2 out of 2 resident not receiving Hospice services used half-bed rail for mobility but did not have written order from physician which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2024
	Plan of Correction
1 2 3 4	Administrator stated to submit a written plan of action understanding regulation and will ensure residents using half-bed rails for mobility will have a written physician's order in resident file by POC due date. Administrator agreed and understood.

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: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: MAGDALENE RESIDENTIAL CARE	FACILITY NUMBER: 435202646
	VISIT DATE: 07/30/2024

NARRATIVE

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Fire extinguisher was observed and inspected on 10/01/2022 and ADM provided receipt for fire inspection renewal on 05/19/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 06/03/2024.

LPA Rai reviewed facility records for 3 staff and 3 residents. Based on review staff (S1)'s file, S1's first aid was expired and did not have updated first aid training. LPA Rai reviewed resident medications and central stored medication records. Based on review of 1 resident (R2), Centrally Stored Medication Record/Log, 1 centrally stored prescription medication was not logged on the document.
Based on review of resident R2 and R4's file, 2 out of 2 resident records did not have a written order from a physician indicating the need for the postural support, such has the half-bed rail for mobility.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. Technical Assistance was provided. This report was reviewed with Lead Staff, Ellenelsa Lopez and LPA Rai reviewed this report with Administrator, Fe Literato-Hilario over the phone. Administrator verbally agreed and understood. A copy of the report was provided and Appeal Rights were provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC809 (FAS) - (06/04)

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