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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202796
Report Date: 04/27/2023
Date Signed: 05/10/2023 05:07:20 PM

Document Has Been Signed on 05/10/2023 05:07 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:MADISON HOUSE LLC, THEFACILITY NUMBER:
435202796
ADMINISTRATOR:WANG, YINGFACILITY TYPE:
740
ADDRESS:329 EL PORTAL WAYTELEPHONE:
(408) 618-5389
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 6CENSUS: 4DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Ying Wang - AdministratorTIME COMPLETED:
03:51 PM
NARRATIVE
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***This is an amended report for facility visit date 4/27/2023.

Licensing Program Analysts (LPAs) Trang Pham and Ryker Herbele, arrived unannounced to conduct an annual required one year inspection. LPAs met with Ying Wang, Administrator.

LPAs toured the facility inside and outside including the residents' bedrooms, bathrooms, kitchen, garage, backyard and storage shed. LPAs observed 2 days worth of perishable and 7 days worth of non-perishable food ready for the number of residents at the facility.

4 out of 4 resident bedrooms were observed to have beddings, sheets, functioning lights and sufficient storage space. 2 out of 4 resident beds were observed to have full bed rails.
The facility does not currently have any current exceptions in place for full bed rails, and no residents at the facility are currently on hospice.

2 of the bedrooms were observed to have unobstructed sliding doors. 2 out of 2 resident bathrooms are observed to have grab bars and non-skid mats. Hot water temperature in 2 out of 2 bathrooms was measured at 133.5 degrees Fahrenheit, 13.5 degrees outside of the acceptable limit of 105-120 degrees Fahrenheit. Administrator adjusted hot water during visit Hot water was re-measured at 123 degrees Fahrenheit.

LPAs tested facility's smoke detectors and carbon monoxide detectors and all were functional. Fire extinguisher was last serviced on 10/2022.

See LIC 809C
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Trang Pham
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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 8
Document Has Been Signed on 05/10/2023 05:09 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/09/2023 11:21 AM


Created By: Trang Pham On 04/27/2023 at 01:12 PM
Link to Parent Document Below:
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: MADISON HOUSE LLC, THE
FACILITY NUMBER: 435202796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 due to 2 out of 5 resident beds having a full bed rail without current exceptions or hospice agreements, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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***This is an amended report for facility visit 4/27/2023

Licensee shall remove full bed rails for 2 out of 5 residents. Licensee shall submit exception requests for 2 residents to be allowed to use full bed rails to the department by POC due date.
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows... (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). 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 2 out of 2 bathroom sinks whose temperatures were recorded at 133.5*F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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***This is an amended report for facility visit 4/27/2023

Administrator adjusted hot water temperature during visit. Hot water temperature was re-measured in 2 out of 2 bathroom sinks. Hot water temperature was re-measured at 123 degrees Fahrenheit. Licensee shall begin to keep a hot water temperature log and submit to CCL a copy of the hot water temperature log showing the hot water temperature for the past 2 weeks to the department 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:Jackie Jin
LICENSING EVALUATOR NAME:Trang Pham
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 05/10/2023 05:10 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/09/2023 11:35 AM


Created By: Trang Pham On 04/27/2023 at 01:30 PM
Link to Parent Document Below:
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: MADISON HOUSE LLC, THE
FACILITY NUMBER: 435202796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by:
Deficient Practice Statement
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***This is an amended report for facility visit on 4/27/2023

Based on records review, the licensee did not comply with the section cited above in 1 out of 4 staff records reviewed was not complete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
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***This is an amended report for facility visit on 4/27/2023

Licensee shall obtain necessary documents and compile staff file to have all required documents. Licensee shall submit completed staff file to the department by POC due date .
Type B
Section Cited
CCR
87465(h)(6)
(h) The following requirements shall apply to medications which are centrally stored... (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year… This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above, as 4 out of 4 resident medication lists were observed to contain incorrect/incomplete information, information listed on residents' medication did not match the information logged in the Centrally Stored Medication Destruction Record LIC 622, including mismatched prescription numbers, mismatched expiration dates, and missing discontinuation orders. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
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***This is an amended report for facility visit on 4/27/2023

Licensee shall submit an Action Plan to explain how the facility will ensure Centrally Stored Medication Destruction Record LIC 622.is accurate with the residents' current prescription/non-prescription medication to the department 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:Jackie Jin
LICENSING EVALUATOR NAME:Trang Pham
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


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: MADISON HOUSE LLC, THE
FACILITY NUMBER: 435202796
VISIT DATE: 04/27/2023
NARRATIVE
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***This is an amended report for facility visit on 4/27/2023.

Centrally stored medications, toxins, and sharp objects were locked and inaccessible to the residents. LPAs reviewed residents' and staffs' records, 1 out of 4 staffs' files reviewed to be found to be incomplete. Staff member with incomplete file was found to have an up to date finger-print clearance per Guardian, but the facility does not have a physical copy of their criminal background transfer.

LPAs reviewed the centrally stored medication log for 4 out of 4 residents. 4 out of 4 residents' medication storages were observed to be complete. However, information listed on residents' medication did not match the information logged in the Centrally Stored Medication Destruction Record LIC 622, including mismatched prescription numbers, mismatched expiration dates, and missing discontinuation orders.

Deficiencies cited, see LIC809 as per California Code of Regulations Title 22.

This report was reviewed with Administrator Ying Wang on 04/27/2023 and a copy of the report was provided.

Appeal Rights were given to Administrator Ying Wang.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Trang Pham
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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