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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202665
Report Date: 07/16/2021
Date Signed: 07/16/2021 03:39:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LOMA CLARA SENIOR LIVINGFACILITY NUMBER:
435202665
ADMINISTRATOR:JOLIE C. HIGGINSFACILITY TYPE:
740
ADDRESS:16515 BUTTERFIELD BLVDTELEPHONE:
(669) 258-3500
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:89CENSUS: 59DATE:
07/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Sarah Serpa, Generation Program DirectorTIME COMPLETED:
02:33 PM
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Licensing Program Analyst (LPA) Christine Dolores and Licensing Program Manager (LPM) Jackie Jin conducted an unannounced case management visit to discuss an incident report submitted to CCL regarding a resident. LPA and LPM met with Sarah Serpa, Generations Program Director.

It was reported that R1 was being help against his will and R1 made sexual advancements to staff.

LPA and LPM interviewed Resident Care Director, Generation Program Director, and R1 regarding the incident. During interviews, facility staff and resident denied the incident that occurred at the facility.

Resident Service Director and Generation Program Director created a plan of action that consist of communication with family and R1's physician regarding behavior and suggestion for a psychological evaluation. R1's medication will be given in the dining room and when staff is not comfortable in going into R1's apartment alone, they will ask another staff to accompany staff into apartment.

LPA and LPM obtained a copy of R1's physician report, needs and services plan, and care notes.

No deficiencies cited during today's visit.

This report was reviewed with Sarah Serpa, Generation Program Director. Copy of this report provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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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