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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202780
Report Date: 05/09/2024
Date Signed: 05/10/2024 08:21:58 AM


Document Has Been Signed on 05/10/2024 08:21 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:SONNET HILLFACILITY NUMBER:
435202780
ADMINISTRATOR:LATU, JASMINEFACILITY TYPE:
740
ADDRESS:429 MERIDIAN AVETELEPHONE:
(408) 731-0019
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:80CENSUS: 36DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jasmine LatuTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Jasmine Latu. LPA toured the facility inside and out with ADM. License, Administrator Certificate, and personal rights posters were observed in the facility. 36 residents and 17 staff were in the facility during LPA's visit. LPA reviewed 5 resident file and 5 staff files.

LPA toured the first floor with ADM including the front desk, the offices, multiple purpose room, dining room, kitchen, living room and restrooms. LPA toured the second floor memory care unit with ADM including 22 apartments, dining room, activity room, living room, laundry room, storage room and restrooms. LPA toured the third floor assisted living Unit with ADM including 30 apartments, Med room, activity room, living room, laundry room, chemical storage room and restrooms.

Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication room, Medication carts, knives closet, and chemical storage room, and laundry rooms were observed locked. Room temperature was at 75 degree F, and hot water temperature was at 110 degree F in facility. The temperature of the refrigerator was at 37 degree F, and the temperature of the freezer was at 0 degree F.

Fire extinguisher was serviced on 06/6/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. ADM showed the test report for smoke detector, fire alarm and elevators dated 4/23/2024, and it shows they were working. First aid box and flash lights were observed in the facility. Courtyard was inspected. There was no obstruction to block the walkways. ADM stated the last time the facility conducted the emergency and fire drill was on 4/26/2024.

Deficiencies were noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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 05/10/2024 08:21 AM - 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: SONNET HILL
FACILITY NUMBER: 435202780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 2 out 3 caregivers were observed without valid first aid certificate which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
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ADM stated to submit the plan of correction by POC due date to have staff to obtain first aid training and certificate
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff were unable to provide 5 out 5 resident central stored medications forms in the resident files poses/posed a potential health, safety risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to maintain resident file accurate and update to 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: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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