435202754-9-5-2024-26-AS-MTAN-D8TVA2-20240905161514

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202754
Report Date: 09/05/2024
Date Signed: 09/05/2024 04:15:31 PM

Document Has Been Signed on 09/05/2024 04:15 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:	PRIMAVERA GARDENS		FACILITY NUMBER:	435202754
ADMINISTRATOR:	MICHAEL ELSOUSOU		FACILITY TYPE:	740
ADDRESS:	16095 CHURCH STREET		TELEPHONE:	(408) 778-5683
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	20	CENSUS: 18	DATE:	09/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Lisa Lanford, Resident Care Supervisor		TIME COMPLETED:	04:20 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 Christine Dolores conducted a required unannounced 1 year visit and met with Resident Care Supervisor (RCS), Lisa Lanford. During the visit LPAs toured the facility inside and out. LPAs toured the kitchen area. LPAs observed a perishable food supply of at least 2 days and a nonperishable food supply of 7 days. Refrigerator temperatures maintained at 35 degrees F. Freezer temperature maintained at -6 degrees F. LPAs toured the resident dining area. LPAs observed a wooden plank in the track of the sliding glass door obstructing the sliding glass door in the dining room. Sliding door leads out to front of facility. Licensee was advised to ensure all exit passageways are free and clear of obstruction. Licensee was advised to remove wooden plank in the track of the sliding glass door due to fire safety hazard. LPAs toured 6 resident rooms. LPAs observed 5 resident rooms (Rooms 1, 2, 3, 4, 5) to have half-bed rails. LPAs observed Rooms 1, 2, 4 and 5 had half-bed rails, and Room 2 had full bed rails. RCS obtained orders for 3 resident's half-rails. LPAs observed the physician's order for the full-bed rails. LPAs recorded bathroom water temperature 120 degrees F in all resident bathrooms. LPAs observed all resident bathrooms had functioning lights and available soap and paper towels. LPAs observed each resident room had available bedding and clothing storage areas. LPAs tested the carbon monoxide detector to be functioning properly. The fire extinguisher last serviced on 7/26/2024. LPAs reviewed 5 resident Centrally Stored Medication and Destruction Record (CSMDR). 5 out of 5 reviewed CSMDR were complete during visit. LPAs reviewed 5 out of 5 resident records to be complete. LPAs were unable to review fire drill logs. RCS states she believes the emergency drills are locked in the office, which RCS is unable to access. See LIC809C.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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: PRIMAVERA GARDENS	FACILITY NUMBER: 435202754
	VISIT DATE: 09/05/2024

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LPAs observed 2 out of 5 staff files are missing health screening and TB result. RCS states files may be locked in the front office which RCS is unable to access. LPAs advised that all personnel files should be available to Licensing agency for reviewing. LPAs were unable to review the administrators file. RCS states the file is locked in the front office, which RCS is unable to access. 5 out of 5 staff obtained fingerprint clearance. 1 out 5 staff have First Aid certification. Annual staff training records were reviewed.

Documents were requested to update the facility file: liability insurance, administrator certification.

Deficiencies were cited per California Code of Regulations Title 22 see LIC809D. This report was reviewed with RCS Lisa Lanford and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/05/2024 04:15 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: PRIMAVERA GARDENS	FACILITY NUMBER: 435202754
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(g)

(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review and interview, the licensee did not ensure 3 out of 5 staff records to include the administrator's records and 2 staff members health screening and TB results were available for review due to being locked in the office, which staff do not have access to, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2024
	Plan of Correction
1 2 3 4	Licensee states she submit a written plan stating she will make her own staff file copies to have in her office to have access at all times. Licensee will submit POC to LPA Tarin by POC due date.

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not ensure emergency drills are being documented and available for licensing review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2024
	Plan of Correction
1 2 3 4	Licenses states she will submit a written plan stating that she conducted emergency drills quarterly and ensure that drills are being documented. Licensee will submit POC to LPA Tarin by POC due date.

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: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

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