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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202779
Report Date: 11/05/2024
Date Signed: 11/26/2024 04:47:00 PM

Document Has Been Signed on 11/26/2024 04:47 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:REAL ELDERLY CAREFACILITY NUMBER:
435202779
ADMINISTRATOR/
DIRECTOR:
ARIES GERONIMOFACILITY TYPE:
740
ADDRESS:4858 POSTON DRIVETELEPHONE:
(408) 440-2441
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:01 PM
MET WITH:JANET SALVADORTIME VISIT/
INSPECTION COMPLETED:
02:52 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management - incident visit and met house manager Janet Salvador (HM). This is an amended report due to new information from 11/5/24.

On 10/30/24, the Department received an incident report reporting that a resident (R1) accidentally took other resident's medication. LPA interviewed Licensee (LCN), ADM, 1 staff, and 2 residents.

During interview, LCN stated on 10/29/2024, he/she received a report from staff S1 that resident R1 had a medication error incident. LCN stated this was the first incident of medication error occurred in the facility. Staff S2 stated he/she found resident R1 took resident R2's medications while he/she was going to administer medication to resident R2.

LPA obtained a copy of the incident report and LCN stated that they had notified R1 doctor regarding the incident. A copy of R1's doctor's instruction was obtained during visit.

LPA reviewed/checked R1's 6 medications with R1's November 2024 centrally stored medication form/log, and they were all matched by counting the amount or number of medication in the bottle and cross referencing log.

During visit on 11/5/24, the Department inadvertently did not issue a citation on the medication error. Therefore, a citation under Title 22, section 87465(a)(4) is being cited for today. Please see LIC809 and LIC809-D for deficiency.

Exit interview was conducted with HM. The report was provided to HM for signature. A copy of the report was provided to HM.
Romeo ManzanoTELEPHONE: (408) 277-1289
Chihhsien ChangTELEPHONE: (408) 904-9843
DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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