435202727-10-16-2023-26-AS-CDOS-CWKRMN-20231013130901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202727
Report Date: 10/13/2023
Date Signed: 10/16/2023 08:22:45 AM

Document Has Been Signed on 10/16/2023 08:22 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:	TRANQUILITY HOME		FACILITY NUMBER:	435202727
ADMINISTRATOR:	LUCERO RODRIGUEZ		FACILITY TYPE:	737
ADDRESS:	17343 SERENE DRIVE		TELEPHONE:	(831) 818-7981
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY: 4		CENSUS: 3	DATE:	10/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	LUCERO RODRIGUEZ		TIME COMPLETED:	01:10 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 inspection. LPA met with Administrator, Lucero Rodriguez. During visit, LPA toured the facility with ADM and resident (R2) to include the office, dining room, kitchen, living room, resident bedrooms, bathrooms, laundry room, garage, and backyard. All fire exit routes were free and clear of obstruction. All sharp objects, cleaning solutions, disinfectants, and medications observed locked. Fire extinguisher last serviced on 08/17/2023. Carbon monoxide observed present in the facility. Sprinkler system observed throughout the facility and last inspected in April 2023. Facility temperature maintained at 68 degrees Fahrenheit. Facility has extra linens and hygiene products available for use. Resident bedrooms observed with bedding, linens, dressers, and lighting. Facility has at least 7 days worth of non-perishables and 2 days worth of perishable foods. LPA observed the facility's emergency supply. Bathrooms observed with grab bars. Hot water temperature in 2 bathrooms maintained between 126 - 129 degrees Fahrenheit. During visit, staff turned down the hot water temperature. LPA observed the facility's transportation vehicle that was parked inside the garage. The transportation vehicle's registration is up to date. Vehicle is supplied with emergency bags, a fire extinguisher, and first aid kit. 3 residents files (R1 - R3) were reviewed. 3 out of 3 residents files contained an admission agreement, medical assessment, TB result, updated IPP and/or IBSPs, personal rights form, consent forms, and safeguard of personal property and valuables form. R1 - R3's P&I money were inspected and observed maintained. SEE LIC809-C.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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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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: TRANQUILITY HOME	FACILITY NUMBER: 435202727
	VISIT DATE: 10/13/2023

NARRATIVE

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R1 - R3's centrally stored medication and centrally stored medication records were inspected. LPA observed R3's CSMR was missing information such as start dates and date filled. LPA observed R1 - R3's CSMR did not contain start dates and expiration dates for each medication did not reflect the accurate expiration date on the label.

3 staff files (S1 - S3) were reviewed. 3 out of 3 staff files contained an updated 1st aid certification, fingerprint clearance, LIC501, LIC503, TB information, and LIC9052. S1 - S3's annual training were reviewed to include 16 hours of emergency intervention and infection control. Staff are provided at least 20 hours of continuing education annually. Facility conducts emergency drill at least quarterly with all staff per shift.

LPA reviewed the facility's' infection control plan, emergency disaster plan, and facility file. Posters observed in the facility to include COVID-19 related posters, evacuation plan, and personal rights form.

During visit, LPA obtained a copy of the facility's emergency disaster plan.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. Advisory note provided. This report was reviewed with Administrator, Lucero Roriguez and Director of Operations, David Sandhu and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/16/2023 08:22 AM - It Cannot Be Edited

Created By: Christine Dolores On 10/13/2023 at 12:40 PM

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: TRANQUILITY HOME	FACILITY NUMBER: 435202727
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(k)(7)

(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: 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 ensure R1 - R3's centrally stored medication records were accurate and properly maintained which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2023
	Plan of Correction
1 2 3 4	Licensee will conduct an in-service training with the staff and submit the in-service training document to LPA Dolores via email by POC due date.

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

LICENSING EVALUATOR NAME:

Christine Dolores

LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

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