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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202789
Report Date:
03/08/2024
Date Signed:
03/08/2024 05:52:53 PM
Document Has Been Signed on
03/08/2024 05:52 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:
DELIA'S RESIDENTIAL COMMUNITY 3
FACILITY NUMBER:
435202789
ADMINISTRATOR:
DOMINGO, DINA
FACILITY TYPE:
740
ADDRESS:
175 BLAKE AVE
TELEPHONE:
(408) 799-6239
CITY:
SANTA CLARA
STATE:
CA
ZIP CODE:
95051
CAPACITY:
6
CENSUS:
4
DATE:
03/08/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:20 AM
MET WITH:
Designated Administrator, Carmen Buno
TIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Designated Administrator (DA) Carmen Buno. LPA Rai observed 1 staff (S1) and 3 residents at the facility since 1 resident was out of the facility.
At approximately 9:20am, LPA rang the doorbell and no one answered the door. At approximately 9:35am, the resident (R3) opened the door and stated there was no staff in the home and to wait for someone to come. At approximately 9:30am, staff (S1) opened the door and let LPA enter the facility. S1 stated the employee was newly hired and assisted residents with activities of daily living (ADLs) as a caregiver. S1 stated S1 was not fingerprinted and planned to go today 3/8/2024 to submit the application. Per interview with DA, S1 assisted DA with the residents and DA is aware S1 is not Criminal Background Cleared and DA understands staff who work with residents need to be Criminal Background Cleared before they start to work at the facilty.
During visit, LPA Rai toured the inside and outside of the facility with staff (S2). When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas.
LPA observed a closet next to the front door which was unlocked and contained food supply and cleaning supplies. DA and S2 removed the cleaning supply items to the laundry room. LPA observed the cleaning supply and the laundry detergents located in the cabinets in the laundry room accessible to resident in care. LPA observed laundry detergent under the utility sink next to the laundry machine. At the time of visit, laundry machine was not in use.
Continuation on LIC 802-C, Page 1 out of 3.
SUPERVISOR'S NAME:
Romeo Manzano
TELEPHONE:
(650) 388-2297
LICENSING EVALUATOR NAME:
Simranjit Rai
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE:
03/08/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
16
Document Has Been Signed on
03/08/2024 05:52 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:
DELIA'S RESIDENTIAL COMMUNITY 3
FACILITY NUMBER:
435202789
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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
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Based on observation, the licensee did not comply with the section cited above in the laundry room and hallway closet contained laundry detergent and cleaning solutions where were accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/09/2024
Plan of Correction
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Administrator Designee stated to submit a written plan of action understanding regulation and will ensure to store cleaning solutions where it is inacessible to residents in care by POC due date. Administrator Designee agreed and understood.
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview, the licensee did not comply with the section cited above in staff (S1) was providing care and supervision without obtaining a Criminal Record Clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/09/2024
Plan of Correction
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Administrator Designee stated to submit a written plan of action understanding regulation and will ensure to staff obtains a Criminal Record Clearance by POC due date. Administrator Designee agreed and understood.
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 Manzano
TELEPHONE:
(650) 388-2297
LICENSING EVALUATOR NAME:
Simranjit Rai
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE:
03/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/08/2024
LIC809
(FAS) - (06/04)
Page:
2
of
16
Document Has Been Signed on
03/08/2024 05:52 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:
DELIA'S RESIDENTIAL COMMUNITY 3
FACILITY NUMBER:
435202789
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 2 resident file did not contain a signed LIC 613 Personal Rights which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/15/2024
Plan of Correction
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During visit, Administrator Designee went over LIC 613 Personal Rights with R4. Administrator Designee stated to submit a written plan of action understanding regulation and will ensure new residents will sign the form upon admission by POC due date. Administrator Designee agreed and understood.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 2 resident's file did not contain physician's order for halff-bed rails which would be used as postural support which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/15/2024
Plan of Correction
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Administrator Designee stated to submit a written plan of action understanding regulation and will ensure to request a physician's order for the half-bed rails by POC due date. Administrator Designee agreed and understood.
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 Manzano
TELEPHONE:
(650) 388-2297
LICENSING EVALUATOR NAME:
Simranjit Rai
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE:
03/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/08/2024
LIC809
(FAS) - (06/04)
Page:
3
of
16
Document Has Been Signed on
03/08/2024 05:52 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:
DELIA'S RESIDENTIAL COMMUNITY 3
FACILITY NUMBER:
435202789
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in R3's resident file did not contain an Appraisal/Needs and Services Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/15/2024
Plan of Correction
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Administrator Designee stated to submit a written plan of action understanding regulation and will ensure to assess and create Needs and Service Plan for residents in care by POC due date. Administrator Designee agreed and understood.
Type B
Section Cited
CCR
87457(c)
87457 Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in R4's resident file contained incomplete Needs and Services Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/15/2024
Plan of Correction
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2
3
4
Administrator Designee stated to submit a written plan of action understanding regulation and will ensure to assess and create Needs and Service Plan for residents in care by POC due date. Administrator Designee agreed and understood.
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 Manzano
TELEPHONE:
(650) 388-2297
LICENSING EVALUATOR NAME:
Simranjit Rai
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE:
03/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/08/2024
LIC809
(FAS) - (06/04)
Page:
4
of
16
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:
DELIA'S RESIDENTIAL COMMUNITY 3
FACILITY NUMBER:
435202789
VISIT DATE:
03/08/2024
NARRATIVE
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Page 2 of 3.
LPA Rai toured the resident bedrooms. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. LPA observed 2 out of 4 resident bed had half-side rails and residents were not under Hospice services. DA stated the residents do not have doctor's orders for the residents to use half-side rails and was not aware resident's need physician's order for bedrails. LPA reviewed resident's Admission Agreement and on page 22, the facility stated the procedure of obtaining physician's order for bedrails.
LPA Rai observed prescription medication and over the counter (OTC) medication in 2 out of the 5 residents rooms. DA stated she was not aware of the medications in the resident's room. S2 stated R1 administered the medication themselves and the staff administer the medications for R2 but keep the medications in R2's room. LPA observed R2 medications accessible to residents in care.
The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 115.5 degrees F - 117.1 degrees F. The water temperature in the kitchen sink was 116.5 degrees F.
The temperature of the facility was measured at 72 degrees F on the thermostat.
Fire extinguisher was observed and inspected on 02/04/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 10/4/2023. Per DA and S2, Administrator conducted a disaster drill in January 2024 but could not locate the document. LPA Rai observed an Emergency and Disaster Plan binder which located all drill records for the past 2 years.
LPA Rai reviewed facility records for 2 staff and 2 residents. 2 out of 2 staff files contained documents from when the building was licensed under a different license. DA stated the facility hired some of the staff from the previous license when the Department approved their license. DA stated they retained the old documents and placed them in the file. LPA Rai stated the facilty needs retain documents that are issued from the current Licensee and the previous documentation may not be appropriate.
SUPERVISOR'S NAME:
Romeo Manzano
TELEPHONE:
(650) 388-2297
LICENSING EVALUATOR NAME:
Simranjit Rai
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE:
03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/08/2024
LIC809
(FAS) - (06/04)
Page:
15
of
16
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:
DELIA'S RESIDENTIAL COMMUNITY 3
FACILITY NUMBER:
435202789
VISIT DATE:
03/08/2024
NARRATIVE
1
2
3
4
5
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9
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12
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Page 3 of 3.
R3's resident files did not contain Needs and Services Plan and R3 has a diagnosis of Dementia. R4's resident files did not contain a complete Needs and Services Plan dated 11/8/2022 which is not signed. R4's resident file did not contain LIC 613 Personal Rights. DA reviewed LIC 613 Personal Rights with R4 in his/her room during today's visit. LPA Rai reviewed resident medications and central stored medication records.
A civil penalty is being assessed for the amount of $400 ($100 per day x 4 days = $500), for staff (S1) working at the facility without a Criminal Background clearance transfer. Please see LIC 421BG. Per DA, S1 worked at the facility on February 26, February 27, February 28th and March 8th 2024.
Deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Designated Administrator (DA) Carmen Buno and a copy of the report was provided. Technical Violation and Technical Assistance was provided. Appeal Rights were provided.
SUPERVISOR'S NAME:
Romeo Manzano
TELEPHONE:
(650) 388-2297
LICENSING EVALUATOR NAME:
Simranjit Rai
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE:
03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/08/2024
LIC809
(FAS) - (06/04)
Page:
16
of
16