435202811-10-26-2023-26-AS-CDOS-CWZ2S6-20231026173838

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202811
Report Date: 10/26/2023
Date Signed: 10/26/2023 05:38:45 PM

Document Has Been Signed on 10/26/2023 05:38 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:	SWEET CARE HOME IN GILROY		FACILITY NUMBER:	435202811
ADMINISTRATOR:	YALUNG, ELAINE		FACILITY TYPE:	740
ADDRESS:	318 CHURCHILL PLACE		TELEPHONE:	(510) 458-7231
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	6	CENSUS: 6	DATE:	10/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Evelyn Yalung		TIME COMPLETED:	05:45 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 Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required 1 - year annual inspection. Administrator (ADM), Elaine Yalung was called and states she was unable to meet LPA at the facility. LPA met with Lead Caregiver, Evelyn Yalung. During visit, LPA toured the facility with staff to include the living room, dining room, kitchen, resident bedrooms, staff bedroom, bathrooms, garage, and backyard. All fire exit routes were free and clear of obstruction. 3 staff present are fingerprint cleared and associated to the facility. Facility temperature maintained at 76 degrees Fahrenheit. Facility currently has 4 hospice care residents. (The facility is pending approval for an increase of hospice care residents as of 10/09/2023). 3 residents under hospice care observed with bed rails that extends half the length of the bed. 2 residents did not have a physician's order for half rails in their records. During visit, the 2 resident's hospice care nurse arrived to the facility to drop off their hospice care notes from this morning. Nurse states the residents are provided a physician's order for a "hospital bed", but the physician's order does not specify "half rails". Hospice nurse placed an order for "half rails" and is pending a final signature from the physician. Facility will obtain the order once completed. 1 resident under hospice care observed with full-length bed rails. LPA did not locate the resident's hospice care plan in the facility. ADM emailed resident's hospice care plan to LPA, but LPA did not locate an order for full-length bed rails in the hospice care plan. ADM called the hospice nurse who later sent the physician's order for full-length bed rails signed and dated on 10/26/2023. SEE LIC809-C.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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 10/26/2023 05:38 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: SWEET CARE HOME IN GILROY	FACILITY NUMBER: 435202811
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(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 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by the hot water temperature maintained at 140 degrees Fahreinheit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	Licensee will submit a pictures of the hot water temperature to LPA Dolores via email by POC due date.

Type A

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not ensure to obtain a TB result prior to 2 residents admission which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	Licensee will submit a plan of action to obtain R1 - R2's TB results to LPA Dolores via email 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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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: SWEET CARE HOME IN GILROY	FACILITY NUMBER: 435202811
	VISIT DATE: 10/26/2023

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Facility's kitchen observed with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 50 degrees Fahrenheit. ADM was advised. Freezer temperature maintained below 0 degrees Fahrenheit. Food items observed covered and labeled. Sharp objects, chemicals, and disinfectants observed locked.

Resident bedrooms equipped with beds, clean linens, dressers, night stands, and adequate lighting. Bathroom supplied with hygiene products, grab bars, and paper supplies. Hot water temperature maintained at 140 degrees Fahrenheit. Facility was advised.

LPA reviewed 5 resident records. 2 resident's (R1 - R2) physician's report was last updated in 2021. Both residents are diagnosed with Dementia. R1 - R2 did not have a TB result on file. 5 out of 5 resident's files contained an updated appraisal/needs and services plan, consent form, and personal rights form. LPA and staff reviewed 5 out of 5 resident's centrally stored medications and centrally stored medication records. LPA advised to ensure the centrally stored medication records are completely filled out and to log resident's over-the-counter medications. ADM was advised. LPA reviewed 3 staff records. All the staff records contains a 1st aid certification, fingerprint clearance, health screening, TB results, and job application. Staff are provided training on topics to include dementia care, postural support, and medication. LPA advised to input the training hours on the certificates for 2023.

Facility has an infection control plan and PPE supplies. Staff are trained on infection control. Facility has an emergency disaster plan. Facility has extra batteries and flashlights. First aid kit observed complete with tweezers, scissors, bandages, gauze, and a manual. Staff conducted emergency disaster drills at least quarterly. Fire extinguisher last services on 08/10/2023. LPA observed the facility has smoke detectors that writes "smoke alarm" . ADM states the detectors are wired and a combination of a smoke alarm and carbon monoxide detector. ADM states they had a fire inspection this year and will follow-up with LPA Dolores regarding their fire inspection report.

Documents were requested to include the facility's liability insurance.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed on the phone with Administrator, Elaine Yalung and Lead Caregiver, Evelyn Yalung and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/26/2023 05:38 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: SWEET CARE HOME IN GILROY	FACILITY NUMBER: 435202811
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

(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
1 2 3 4	Based on observation, interview, and record review the licensee did not comply with the section cited above by 2 residents with dementia who did not have an annual physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/02/2023
	Plan of Correction
1 2 3 4	Licensee will submit a plan of action in obtaining an updated physician's report for residents with Dementia to LPA Dolores via email by POC date.

Type B

Section Cited

CCR

87608(a)(3)

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not ensure to retain a physician's order in the resident's records for 2 residents half rails and 1 resident's full length bed rails prior to use which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/02/2023
	Plan of Correction
1 2 3 4	Licensee will submit a statement of understanding of the section cited above to LPA Dolores via email 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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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