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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202824
Report Date: 09/29/2022
Date Signed: 09/29/2022 03:51:37 PM

Document Has Been Signed on 09/29/2022 03:51 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:LYRIC LODGEFACILITY NUMBER:
435202824
ADMINISTRATOR:HAYES, JEFFREYFACILITY TYPE:
735
ADDRESS:1306 VINCI PARK WAYTELEPHONE:
(669) 284-8920
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 6CENSUS: 0DATE:
09/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:HAYES, JEFFREYTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores and Licensing Program Manager (LPM) Cara Smith arrived unannounced to open an initial complaint investigation and met with Administrator, Jeffrey Hayes. During visit, LPA and LPM conducted a Case Management - Deficiencies visit.

Upon arrival, 1 client (C1) observed on site. LPA and LPM interviewed C1 before leaving for day program. No clients observed on site. Administrated stated all clients were attending day program. LPA and LPM toured the facility with the Administrator to include the bedrooms, bathroom, kitchen, living rooms, garage, and backyard.

At 09:37am, LPA and LPM observed multiple medications in the common areas not kept in a safe and locked place that is inaccessible to clients in care. Medications were secured during visit.

At 09:37am, LPA and LPM observed the smoke detector and carbon monoxide detector to not be installed. Administrator stated to be changing the batteries for the detectors. Administrator installed the detectors during visit.

At 09:39am, LPA and LPM observed knives and sharp objects in the kitchen cabinets that were not locked and stored inaccessible to clients in care. Knives and sharp objects were secured immediately.

At 09:41am, LPA and LPM observed the facility's refrigerator did not have at least 2 days worth of perishables and fresh vegetables. Administrator stated a plan to go grocery shopping today or tomorrow.

See LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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 4
Document Has Been Signed on 09/29/2022 03:51 PM - It Cannot Be Edited


Created By: Christine Dolores On 09/29/2022 at 10:59 AM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LYRIC LODGE
FACILITY NUMBER: 435202824

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2022
Section Cited
CCR
80087(g)(1)

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(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement was not met as evidenced by:
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Administrator immediately secured the knives, sharp objects, and toxins. Licensee will review and train all staff on section 80087 and send the staff training to LPA by email by POC due date.
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Based on observation and interview, licensee did not ensure to lock toxins in the laundry room and all knives and sharp objects in the kitchen cabinets which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
09/30/2022
Section Cited
CCR80075(k)(1)

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(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement was not met as evidenced by:
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Administrator secured the medications during visit. Licensee will review and train all staff on section 80075 and send the staff training to LPA by email by POC due date.
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Based on observation and interview, licensee did not ensure to lock and secure multiple medications in facility's common areas which poses an immediate health, safety, and personal rights risk to persons in care.
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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
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2022 03:51 PM - It Cannot Be Edited


Created By: Christine Dolores On 09/29/2022 at 02:33 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LYRIC LODGE
FACILITY NUMBER: 435202824

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2022
Section Cited
CCR
85068.4(g)

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(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual ...
This requirement was not met as evidenced by:
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Licensee will submit an exception request regarding the retention of individuals 60 years of age or older to the Department by POC due date.
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Based on record review, the licensee did not ensure to submit an exception request regarding the retention of individuals 60 years of age or older. Facility has 4 out of 5 residents who are over age.
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Type B
10/06/2022
Section Cited
CCR80070(a)

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(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
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Licensee will send the Department a plan to maintain accurate, current, and complete records for all clients to LPA by email by POC due date.
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Based on record review and observation, the licensee did not ensure to retain accurate, current, and complete records for all clients which poses a potential health, safety, and personal rights risk to persons in care.
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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
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: LYRIC LODGE
FACILITY NUMBER: 435202824
VISIT DATE: 09/29/2022
NARRATIVE
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At 10:30am, LPA and LPM observed the facility did not maintain accurate, current, and complete client records.

Based on record review, the facility retains 4 out of 5 clients which are over 60 years of age. Administrator did not submit an exception request to the Department.

Visit was adjourned at 11:20am and LPA and LPM returned to the facility at 2:20pm to deliver report.

Deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided. This report was reviewed with Jeffrey Hayes and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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