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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202727
Report Date: 07/01/2024
Date Signed: 07/01/2024 01:13:43 PM

Document Has Been Signed on 07/01/2024 01:13 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:TRANQUILITY HOMEFACILITY NUMBER:
435202727
ADMINISTRATOR/
DIRECTOR:		LUCERO RODRIGUEZFACILITY TYPE:
737
ADDRESS:17343 SERENE DRIVETELEPHONE:
(831) 818-7981
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 4CENSUS: 3DATE:
07/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Lucero RodriguezTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Administrator, Lucero Rodriguez.

The purpose of the visit is to follow-up on a missed medication for resident (R1) from 01/29/2024 and to follow-up on the facility’s building and grounds.

On 01/31/2024, the Department received an incident report regarding resident (R1)’s missed morning medication on 01/29/2024. Based on interview, R1 had a new medication that arrived on 01/29/2024 and the staff accidentally did not administer one of the medications. The medication error was caught on the morning of 01/30/2024. The facility has two staff members who administers the medication and a verifier who verifies the medication administration. After the incident, 2 out of 2 staff members were provided an updated training on after the incident: making sense of what went wrong to prevent future incidents and medication dispensation. R1’s physician and responsible party was informed. No adverse reaction was noted. LPA obtained the following documents: 2 out of 2 staff member's training records, R1's MAR, R1's medication order, and email correspondence.

On 05/02/2024, the facility had a semi-annual review with DDS. During the review, it was noted that the facility’s dishwasher was out of alignment causing the right side of the dishwasher to stick out approximately 2 inches further than the left side, the cabinet door lock on the kitchen cabinet used to store cleaning agents / chemicals was broken, the toilet paper holder in bathroom #2 was broken, the baseboard under the sink of bathroom #2 was detached from the cabinetry, and the toilet in bathroom #2 was reported to be “leaky”. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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: 07/01/2024
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On 07/01/2024, LPA Dolores toured the facility with staff and observed the following:

- At 10:24AM, LPA entered the kitchen and observed the dishwasher to be maintained. LPA did not observed the dishwasher was out of alignment.
- At 10:25AM, LPA opened the cabinet underneath the kitchen sink and observed the cabinet that stored chemicals and disinfectants was unlocked. Staff immediately locked the cabinet. LPA did not observe the cabinet was broken.
- At 10:30AM, LPA entered into bathroom #2 and observed the toilet paper roll holder was broken and baseboard under the sink was detached from the cabinetry. Administrator states they had put in a work order to have these items repaired. Photographs were obtained using LPA’s state issued cell-phone.
- At 10:30AM, LPA observed the floor of bathroom #2 to be wet. Staff states the floor is wet due to the walk-in shower and not due to the toilet. Staff states the toilet is not leaky.

LPA obtained a print out of the work order for the cabinet baseboard and toilet paper holder.

During visit, staff removed half of the toilet paper holder from the bathroom. Staff states R1 is assisted with toileting. LPA observed toilet paper inside the bottom left drawer of the kitchen sink.

Deficiencies were cited today per California Code of Regulations, Title 22. See LIC809-D.

This Report was reviewed with Administrator, Lucero Rodriguez and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2024 01:13 PM - It Cannot Be Edited


Created By: Christine Dolores On 07/01/2024 at 11:10 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: TRANQUILITY HOME
FACILITY NUMBER: 435202727

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2024
Section Cited
CCR
80075(b)

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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
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Licensee has conducted staff training on after the incident and medication dispensation with the staff involved. Deficiency was corrected during visit.
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Based on interview and record review the licensee did not ensure resident (R1) was administered a prescription medication resulting in the medication being missed which poses an immediate health, safety, and personal rights risk to persons in care.
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Request Denied
Type A
07/02/2024
Section Cited
HSC80087(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
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Licensee has a work order to repair the baseboard underneath the bathroom sink and toilet paper holder. Licensee will submit a statement of understanding of the section cited to LPA Dolores via email by POC due date.
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Based on interview, record review and observation the licensee did not ensure the facility is in good repair which poses an immediate health, safety, and personal rights risk to persons in care.
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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: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/01/2024 01:13 PM - It Cannot Be Edited


Created By: Christine Dolores On 07/01/2024 at 11:16 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: TRANQUILITY HOME
FACILITY NUMBER: 435202727

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/02/2024
Section Cited
CCR
80087(g)

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(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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Staff immediately locked the cabinet. Licensee will conduct an in-service training with staff regarding the section cited. Licensee will submit the training document to LPA Dolores via email by POC due date.
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Based on interview and observation the licensee did not ensure the chemicals and disinfectants were locked underneath the kitchen sink which poses an immediate health, safety, and personal rights risk to persons in care.
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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: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024


LIC809 (FAS) - (06/04)
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