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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202665
Report Date: 07/14/2023
Date Signed: 07/14/2023 10:19:19 AM


Document Has Been Signed on 07/14/2023 10:19 AM - 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:LOMA CLARA SENIOR LIVINGFACILITY NUMBER:
435202665
ADMINISTRATOR:JAIRUS CABUENAFACILITY TYPE:
740
ADDRESS:16515 BUTTERFIELD BLVDTELEPHONE:
(669) 258-3500
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:89CENSUS: 60DATE:
07/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Becca BlackTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the complaint findings for complaint control number 26-AS-20220830100730. During visit, a case management – deficiencies visit was conducted due to violations observed during the complaint investigation. LPA met with Interim Executive Director, Becca Black.

On 07/10/2022, resident (R1) tested positive for COVID-19. From 07/11/2022 - 07/17/2022, R1 was noted to have symptoms and became progressively became weak. On 07/18/2022, R1 was sent to the hospital for medical treatment after being assessed by an outside agency medical professional.

Based on record review, from 07/11/2022 – 07/17/2022, there was no indication that a physician was being notified of R1’s condition. The facility was also unable to produce documents to prove R1’s physician was being notified of R1’s condition during 07/11/2022 – 07/17/2022.

Based on complaint investigation interviews, it was stated the facility’s procedures are to inform the resident’s physician and/or responsible party if a resident has a change of condition.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Interim Executive Director, Becca Black and Generations Program Director Maria Martinez and a copy of the report was appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
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 07/14/2023 10:19 AM - 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: LOMA CLARA SENIOR LIVING
FACILITY NUMBER: 435202665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2023
Section Cited
CCR
87705(b)(1)

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(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes. This requirement was not met as evidenced by:
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Licensee will provide an in-service training to all-staff regarding section 87705(b)(1). Licensee will submit the in-service training document to LPA via email by POC due date.
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Based on interview, record review and observation the licensee did not ensure to inform resident (R1)’s physician of any changes of condition while being diagnosed with COVID-19 which poses an immediate health, safety, and personal rights risk to persons in care.
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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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
LIC809 (FAS) - (06/04)
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