435202743-11-14-2024-26-AS-MTAN-DB22ML-20241114163119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202743
Report Date: 11/14/2024
Date Signed: 11/14/2024 04:31:31 PM

Document Has Been Signed on 11/14/2024 04:31 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:	CAMPBELL SENIOR LIVING		FACILITY NUMBER:	435202743
ADMINISTRATOR/ DIRECTOR:	MERLA BANGLAYAN		FACILITY TYPE:	740
ADDRESS:	426 DALLAS DR		TELEPHONE:	(408) 628-4158
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	11/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Administrator, Merla Banglayan		TIME VISIT/ INSPECTION COMPLETED:	04:30 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 Analysts (LPAs) Marcella Tarin and Kenneth Madrigal conducted an unannounced annual inspection visit, and met with Administrator Merla Banglayan. LPAs toured the facility inside and out to include kitchen, dining area, resident rooms and 2 restrooms. LPAs observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days.The front yard and backyard of the facility was also inspected. All emergency exits were free and clear of construction. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. LPA's measured hot water temperature between 118 and 120 degrees F LPAs observed Tide pod detergent in a hallways closet outside of bedroom #4. LPAs advised Administrator all cleaning products need to be locked and inaccessible to residents. LPAs toured 3 resident bedrooms. 3 out of 3 resident bedrooms had functioning lights, a bed, a chair, dresser and storage room for resident's personal belongings. In R3's bedroom, LPAs observed prescription medication and medicated creams and toenail clippers in a drawer accessible to resident. LPAs advised Administrator all medications need to be locked an inaccessible to residents. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested. Fire extinguishers were last serviced on 08/11/2024. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed. The facility's last drill was on 10/16/2024. See LIC809-C

Jin Jackie	TELEPHONE: (714) 319-3786
Marcella Tarin	TELEPHONE: (714) 328-5152
	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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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Document Has Been Signed on 11/14/2024 04:31 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: CAMPBELL SENIOR LIVING	FACILITY NUMBER: 435202743
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed Tide cleaning pods in a hallway closet outside of Room #4 and prescription medication and creams in a drawer in R3's room accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	Administrator states R3's medication will be removed from room and locked away, Tide detergent pods were also removed and locked. Administrator states all medication and detergents will be locked and inaccessible. Licensee will submit a written letter of understanding of regulation to LPA Tarin by POC due date 11/16/2024.

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.

Jin Jackie	TELEPHONE: (714) 319-3786
Marcella Tarin	TELEPHONE: (714) 328-5152
	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: CAMPBELL SENIOR LIVING	FACILITY NUMBER: 435202743
	VISIT DATE: 11/14/2024

NARRATIVE

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LPAs reviewed records for 3 staff and 5 clients, which were all found to be complete during review.

LPAs reviewed 5 clients Centrally Stored Medication and Destruction Records. 4 out of 5 CSMDRs were reviewed to be completed. 1 out of 5 CSMDRs was found to not have 2 prescription refills documented.

A deficiency was cited during today's visit as per California Code of Regulations Title 22. A Technical Violation was also issued. See LIC9102 for more information. This report was reviewed with ADM Merla Banglayan and a copy of the signed report was provided.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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