435202665-2-16-2024-26-AS-CDOS-D2J3AT-20240216170516

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202665
Report Date: 02/16/2024
Date Signed: 02/16/2024 05:05:24 PM

Document Has Been Signed on 02/16/2024 05:05 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:	LOMA CLARA SENIOR LIVING		FACILITY NUMBER:	435202665
ADMINISTRATOR:	JAIRUS CABUENA		FACILITY TYPE:	740
ADDRESS:	16515 BUTTERFIELD BLVD		TELEPHONE:	(669) 258-3500
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	89	CENSUS: 76	DATE:	02/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Eugenia Smith		TIME COMPLETED:	05:10 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 Executive Director (ED), Eugenia Smith. LPA toured Generations (aka Memory Care) with ED to include 6 apartments (RM 119, 201, 204, 111, 114, and 115), bathrooms, activity room, dining room and kitchen. 6 apartments equipped with beds, linens, chairs, dressers, night stands and adequate lighting. LPA observed 2 residents who uses oxygen. Oxygen in use sign posted outside of resident apartments. Temperature in Generations observed between 72 - 76 degrees Fahrenheit. All fire exit routes were free and clear of obstruction. No observations of chemicals, sharp objects, or items which could pose a danger that are accessible to residents in care. LPA reviewed 4 resident files in Generations. 4 out of 4 resident files contained an updated medical assessment, TB result, service plan, emergency/contact information, admission agreement, safeguard of personal property and valuables, and personal rights form. LPA observed the residents who are using oxygen and half rails contained physician's orders on file. LPA reviewed 4 residents centrally stored medications and centrally stored medication records. Resident (R1)'s medications were counted and observed with extra dosages of medications for 4 bubble pack medications. Facility was unable to track where the discrepancy had stemmed from as the electronic MAR shows that staff had signed off on the administration of the medications daily. LPA entered the kitchen with ED. The facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 36 degrees Fahrenheit. Items inside the refrigerator observed covered and labeled. Freezer temperature maintained at 0 degrees Fahrenheit. 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: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

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: LOMA CLARA SENIOR LIVING	FACILITY NUMBER: 435202665
	VISIT DATE: 02/16/2024

NARRATIVE

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LPA toured Assisted Living with ED to include 5 resident apartments (RM 226, 241, 239, 219, and 214), bathrooms, activity room, fitness center, salon, kitchen, and dining room. 5 resident apartments equipped with beds, linens, chairs, dressers, night stands and adequate lighting. Hot water temperature in RM 226 and 219 maintained at 110 degrees Fahrenheit. Temperature in assisted living measured at 72 degrees Fahrenheit. All fire exit routes are free and clear of obstruction. Fire extinguisher last serviced on 01/09/2024. LPA observed the presence of fire detectors / carbon monoxide detectors throughout the facility. Elevator observed in working condition.

LPA reviewed 4 resident records in Assisted Living. 4 out of 4 resident files contained an updated medical assessment, TB result, service plan, emergency/contact information, admission agreement, safeguard of personal property and valuables, and personal rights form. Medication room observed locked. The medication room is equipped with supplies for hand hygiene, a lidded trash bin, and separate container for sharps. LPA observed the facility's electronic medication administration record which logs PRN medication.

LPA reviewed 5 staff files to include a health screening, TB result, fingerprint clearance, job application, and employee rights. Facility has at least one staff present per shift who obtains a 1st Aid Certification to include Med-Techs and Directors. LPA reviewed 5 out of 5 staff training records. 3 out of 5 staff are provided at least 20 hours of annual training on topics to include but not limited to Alzheimer's, ADL care, Infection control, Dementia care, proper positioning, and hospice.

Facility has an emergency disaster plan and is currently in the process of updating the plan. ED advised to provide the Department a copy of the updated plan once completed. Emergency drills are conducted quarterly, the last drills were completed on 08/02/2023, and 09/04/2023, 11/13/2023, and 01/29/2024. LPA observed flash lights located in the medication room. Facility has an updated and complete infection control plan. LPA observed the facility has sufficient PPE supplies. LPA observed residents participating in activities throughout my visit.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Executive Director (ED), Eugenia Smith, Julie Mayder, Maria Martinez, Cassandra Pace, Rubin Aguila, Anissa Padilla, Rebecca DiRubio and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/16/2024 05:05 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: LOMA CLARA SENIOR LIVING	FACILITY NUMBER: 435202665
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. 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 out of 4 counts in which resident (R1) was not provided with the correct dosage for 4 medications, which contained extra dosages in the bubble packs which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2024
	Plan of Correction
1 2 3 4	Licensee will provide an in-service training to appropriate staff regarding medication administration. Licensee will provide the in-service training document to LPA Dolores via email by the end of day of 02/17/2024.

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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC809 (FAS) - (06/04)

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