435202665-2-13-2025-26-AS-CKAI-DDV24H-20250213160358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202665
Report Date: 02/13/2025
Date Signed: 02/13/2025 04:04:08 PM

Document Has Been Signed on 02/13/2025 04:04 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/ DIRECTOR:	EUGENIA SMITH		FACILITY TYPE:	740
ADDRESS:	16515 BUTTERFIELD BLVD		TELEPHONE:	(669) 258-3500
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY: 89	TOTAL ENROLLED CHILDREN: 0	CENSUS: 74	DATE:	02/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Eugenia Smith		TIME VISIT/ INSPECTION COMPLETED:	04:10 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 Kabariti arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Executive Director, Eugenia Smith. LPA toured Generations (aka Memory Care) with ED to include 4 apartments (RM 113, 109, 105, and 101), bathrooms, activity room, kitchen, and dining room. All fire exit routes were free and clear of obstruction. Temperature maintained between 70 - 72 degrees F. Kitchen refrigerator temperature maintained at 40 degrees F. The beverage refrigerator maintained at 38 degrees F. Freezer temperature maintained below 0 degrees F. Hot water temperature measured between 119.6 - 120 degrees F in RM 113 and 109. Chemicals and disinfectants observed locked. 2 residents in 1 out of 4 rooms is able to store their own hygiene products per their medical assessment. LPA advised ED to take appropriate measure to ensure all resident's safety for those who may wander and is at risk if given direct access to hygiene items. During visit, the facility added a magnetic log on the cabinets in the resident bedroom. Daily program / activities calendar observed posted for the month. During visit, resident's observed participating in activities. 2 resident files in Generations was reviewed. 1 out of 2 resident's who uses a postural support has a physician's order on file. 2 out of 2 resident's physician's report observed outdated from 2022 and 2023. Resident #1 had a medical assessment from a doctor's visit in January 2025. LPA observed the medical assessment did not contain all required information as stated in Title 22 Section 87458. During visit, ED faxed the resident #1 and #2's doctor the facility's physician form. The remainder of the resident files observed complete. LPA inspected 2 resident's centrally stored medication and records. 2 out of 2 resident medications were complete and no issues noted. See LIC809-C.

Jackie Jin	TELEPHONE: (714) 319-3786
Christine Kabariti	TELEPHONE: (408) 324-2112
	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

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: 02/13/2025

NARRATIVE

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LPA entered in the kitchen with the ED. The facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Walk-in refrigerator temperature maintained at 34 degrees F. Walk-in freezer temperature maintained at -33 degrees F. Items inside the refrigerator and freezer observed covered.

LPA toured Assisted Living with ED to include 4 resident apartments (RM 226, 223, 236, and 211). Hot water temperature was measured between 115.3 - 118.9 in RM 226 and 236. 1 out of 4 resident apartments observed with hygiene items and based on review of the resident's physician's report the resident may not have direct access to hygiene items. ED implemented the magnetic lock on resident's cabinet. 2 residents file in Assisted Living was reviewed. 2 out of 2 resident's files were complete. LPA inspected 2 resident's centrally stored medication and records. 2 out of 2 resident medications were complete and no issues noted.

Fire extinguishers observed throughout the facility, last service date was 01/09/2025. Facility has carbon monoxide and smoke detectors present. Fire drills are being completed quarterly and the last drill was completed on 01/30/2025. Elevator observed in working condition. Activities calendar posted throughout assisted living. LPA observed first aid kits in the medication room in Generations and Assisted Living. Facility has a back-up generator and flash lights available, if needed.

4 staff files were reviewed and observed complete. 4 out of 4 staff members had over 20 hours of annual training. LPA advised to ensure appropriate staff receive at least 20 hours of training, in which 8 hours shall be dementia care and 4 hours of which shall be specific to postural supports, restricted health care conditions and hospice care.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. Advisory note provided. This report was reviewed with Executive Director, Eugenia Smith and a copy of the report was provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Kabariti	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/13/2025 04:04 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: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87463(h)

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. 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 4 counts in which 2 residents in Generation's medical assessment was last dated in 2022 and 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/20/2025
	Plan of Correction
1 2 3 4	Licensee corrected the deficiency by following-up with the 2 resident's physicians for the updated LIC602. Going forward, licensee will ensure that all resident's recieve an annual routine visit with a licensed medical profressional once every 12 months.

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.

Jackie Jin	TELEPHONE: (714) 319-3786
Christine Kabariti	TELEPHONE: (408) 324-2112
	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

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