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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202710
Report Date: 10/10/2023
Date Signed: 10/10/2023 11:47:41 AM

Document Has Been Signed on 10/10/2023 11:47 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:VILLAS AT SARATOGA SKILLED NURSING & ASST LVG, THEFACILITY NUMBER:
435202710
ADMINISTRATOR:WILLIAMS, RYANFACILITY TYPE:
740
ADDRESS:20400 SARATOGA LOS GATOS RDTELEPHONE:
(408) 741-2950
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY: 74CENSUS: 31DATE:
10/10/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Karen PadillaTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility’s annual continuation visit from 10/04/2023. LPA met with Clinical Coordinator (CC), Karen Padilla.

The facility has carbon monoxide detectors present throughout the facility. Activities calendar for the month observed posted in the common areas. On 10/04/2023, LPAs observed resident participating in activities such as church service and bingo. On 10/04/2023, LPA entered the kitchen area. The resident's meals are prepared in the facility's skilled nursing section and delivered to assisted living in a food warmer. LPA observed cups of fresh fruits in the assisted living refrigerator which were observed covered.

On 10/04/2023, LPAs reviewed 5 resident records. During review of the residents centrally stored medication record (CSMR) it was found resident R2, R4, and R5's CSMRs were missing information. LPA observed R2 was missing 5 medications that were not written in their centrally stored medication record. CC followed-up with the pharmacy who then sent the updated CSMR with the 5 medications. R2's CSMR was missing start dates and refills information. R4's CSMR was missing start dates and refill number information. R5's PRN medication was not written in the CSMR. During today's visit, LPA observed and obtained the facility's in-service training record on medications that was conducted on 10/04/2023. On 10/04/2023, 4 residents and 3 staff were interviewed.

The following documents were obtained: updated admission agreement, lease agreement, LLC, liability insurance, LIC-500, LIC-610E, and LIC-308.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Clinical Coordinator, Karen Padilla and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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 10/10/2023 11:47 AM - It Cannot Be Edited


Created By: Christine Dolores On 10/10/2023 at 10:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: VILLAS AT SARATOGA SKILLED NURSING & ASST LVG, THE
FACILITY NUMBER: 435202710

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
(h) The following requirements shall apply to medications which are centrally stored: (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
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Based on interview, record review and observation the licensee did not ensure resident R2, R4, and R5’s centrally stored medications records were complete by missing information such as medications, start dates, and refills which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 10/17/2023
Plan of Correction
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Licensee conducted an in-service training on medications on 10/04/2023 with staff. Licensee began correcting residents CSMRs to include their start dates and refill information. Licensee will submit to LPA the facility's policies and procedures regarding medication labeling which will be obtained from the pharmacy to LPA Dolores by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


LIC809 (FAS) - (06/04)
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