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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202724
Report Date: 07/17/2024
Date Signed: 07/17/2024 05:33:59 PM


Document Has Been Signed on 07/17/2024 05:33 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:GOLDWOOD SENIOR CARE HOMEFACILITY NUMBER:
435202724
ADMINISTRATOR:JEANETTE MONGEONFACILITY TYPE:
740
ADDRESS:2692 GOLDWOOD CTTELEPHONE:
(669) 234-3544
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 6DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Licensee, Irish & Justin LadwigTIME COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met Licensee, Irish & Justin Ladwig and stated the purpose of today's visit. LPA Rai observed 2 staff and 6 residents at the facility. At this time, there is 1 resident on Hospice services and facility has a Hospice waiver for 2 residents.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 1 storage shed in the backyard which was not used as habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai toured 4 out of 4 resident bedrooms, which had available bedding, drawers, and functioning lights. LPA Rai observed 1 staff room. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 110.5 degrees F - 110.8 degrees F. The water temperature in the kitchen sink was 110.8 degrees F. Fire extinguisher was observed and inspected on 3/13/2024. Facility smoke detectors and carbon monoxide detectors are in working condition. The last disaster drill was conducted on 4/23/2024.

LPA Rai reviewed facility records for 3 staff and 3 residents. LPA Rai reviewed resident R3's file and observed the resident did not have a written order from the physician to use a half-bed rail. Licensee left a message for R3's physician to obtain written order for the half-bed rail. Licensee and Lead Staff stated R3 is not under Hospice or Palliative care.

Continuation on LIC 809-C, Page 1 of 2.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 07/17/2024 05:33 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: GOLDWOOD SENIOR CARE HOME
FACILITY NUMBER: 435202724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608(a)(3) Postural Supports. A written order from a physician indicating the need for the postural support shall be maintained in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in Resident R3 has a half-side rails on their beds without a written order from a physician, which poses a potential health, safety or personal rights risk to persons in care. R3 are not under Hospice services.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee Irish Ladwig stated they will obtain a written order from a physician for R3 and email a copy to LPA Rai. Licensee will submit a written plan on facility's policy and procedure on obtaining written order from physician for half-side rails by the POC 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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 07/17/2024 05:33 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: GOLDWOOD SENIOR CARE HOME
FACILITY NUMBER: 435202724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
87465(h)
(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 observation, interview and record review, the licensee did not comply with the section cited above in resident R2's medication #1 PRN order did not have a start date on the Centrally Stored Medication log and 12 doses were administered to R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee stated to submit a written plan of action understanding regulation and in-service training on medication administration and maintaining accurate records by POC due date. Licensee agreed and understood.
Type B
Section Cited
CCR
87207
87207 False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above R2's Centrally Stored Medication Log was not accurated logged wherein Lead Staff wrote medication #1 was started on 7/11/2024 but during interview, Lead Staff verbally stated the medication was started on 7/10/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee stated to submit a written plan of action understanding regulation and in-service training on medication administration and maintaining accurate records by POC due date. Licensee agreed and understood.
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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5


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: GOLDWOOD SENIOR CARE HOME
FACILITY NUMBER: 435202724
VISIT DATE: 07/17/2024
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LPA Rai reviewed resident medications and central stored medication records. LPA Rai observed R2's medication records wherein medication #1 was given to R2 routinely 0.5 tablet a day at bedtime and PRN as needed. The different medication orders have separate bubble pack, so there are two bubble pack for medication #1. The centrally stored medication log had recorded the date the medication #1 routine medication was started on 7/11/2024 but the log does not state when the medication #1 PRN medication was started. Based on the observation of the bubble pack for medication #1 PRN, 13 0.5 tablets are not in the bubble pack which indicated the medication was administered to the resident. The Centrally Stored Medication log did not log if medication was disposed/destroyed under the Medication Destruction Record.

The facility staff recorded the medication administered to R2 on the MAR (Medication Administration Record), which indicated the routine medication #1 was given from 7/11/2024 - today 7/17/2024 and the PRN was administered from 7/5/2024-7/17/2024. Based on the medication date filled and the medication administered, the resident should be given 7 doses for routine medication and 13 doses for PRN medication. However, when Licensee, Lead Staff and LPA Rai counted the medication in the bubble pack for medication #1 both routine and PRN, the medication doses given to resident R2 were 21. There is one dose of medication that was given which was not recorded on the MAR. Lead staff stated the medication #1 was started on 7/10/2024 and not on 7/11/2024 as recorded on the Centrally Stored Medication log. Licensee understood the Centrally Stored Medication Log needs to be completed accurately.

Deficiencies were cited per California Code of Regulations, Title 22. Technical Assistance was provided. This report was reviewed with Licensee, Irish & Justin Ladwig and a copy of the report was provided. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5