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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202862
Report Date: 07/30/2024
Date Signed: 10/28/2024 09:45:17 PM

Document Has Been Signed on 10/28/2024 09:45 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HANSELL VILLAFACILITY NUMBER:
435202862
ADMINISTRATOR/
DIRECTOR:		ELIZABETH BAUTISTAFACILITY TYPE:
740
ADDRESS:5343 HANSELL DRIVETELEPHONE:
(408) 362-9195
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 6DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Elizabeth Bautista AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 7/30/2024 at 2:00 p.m.. Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived and conducted an unannounced required 1 year inspection visit. LPA was greeted by 2 staff and administrator Elizabeth Bautista. LPA stated the purpose of the visit.

LPA observed a NO SMOKING OXYGEN IN USE sign posted on the exterior of the facility and 2 of 4 resident's room door. ADM stated oxygen is used by resident in room 2 and 4 as needed only.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed to serve ages 60 and over 6 non-ambulatory, 1 out 6 may be bedridden and a waiver for 2 hospice care. The facility's has 6 residents (R1 to R6) that have neurocognitive impairment. 2 staff were present at the time of the visit. 6 residents were present at the facility and 1of 6 were in the living/dining area. LPA observed 5 of 6 residents are in the bedroom and 1 out of 6 residents are under hospice care. Based on document review, the facility does not have a waiver for hospice care.

At 2:15 p.m. LPA toured the facility inside and outside with ADM, including but not limited to the kitchen, bathroom, dining room, living room, residents rooms, staff room, backyard and walkways. LPA observed the Personal Rights disclosure, Long Term Care Ombudsman (LTCO) and Centralized Complaint and Information Bureau (CCIB) of the CA Department of Social Services (CDSS) prominently posted on the wall, visible to visitors, resident and staff. The temperature inside the home was at 68 to 69.8 degrees F.

LPA and ADM toured the 4 bedrooms and LPA observed the rooms to be organized and free from debris and has sufficient storage for resident's personal belongings. Resident's bedroom has a call alarm system to alert staff if assistance is needed. Three resident bedrooms (Rooms #2 and 3) have sliding exit doors that are free from obstruction. 2 of 4 bedroom is shared by 2 residents. LPA observed 6 of 6 residents' bedroom are sanitary and free from debris.

page 1 - see LIC 809C for page 2
*due to technical difficulty while saving the document the ADMs signature was not captured.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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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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: HANSELL VILLA
FACILITY NUMBER: 435202862
VISIT DATE: 07/30/2024
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Based on observation R1 who is under hospice care is able to move from side to side, is able to do 1 or 2 activity of daily living such as eating, drinking and stand with assistance.

LPA observed that the facility has a wall pull fire alarm system but it is not connected to the fire department emergency line. The facility has a carbon monoxide alert system that is in good working condition. LPA observed night lights on the hallway. Hallways are free from obstruction. LPA observed ramps and walkways are free from obstruction. LPA observed the backyard area to be free from debris and is maintained.

LPA with ADM toured 2 full bathrooms and both have non-skid mats and grab bars and a raised toilet seat. The facility stores incontinent supplies and unopened, unused cleaning and laundry supplies are kept in a locked cabinet inside the garage. LPA with ADM inspected the staff lounge inside the garage.

LPA tested the water temperature for kitchen and bathrooms, water temperature was measured at 118.9 degree F to 121.9 degree F. Dining and kitchen area and living room area were observed to be sanitary and organized. The facility has sufficient supply of perishable food for 2 days and non-perishable food for 7 days. The fire extinguisher located in the kitchen was last inspected on 3/16/2024.

LPA Reviewed 3 of 6 resident's record and observed them to be complete and up to date, including Centrally Stored Medication and Destruction Record (CSMDR). LPA reviewed 2 staff records and observed the record to be updated. The facility's last disaster drill training was conducted 1/3/2024 1/24/2024, 2/10/2024 and 6/10/2024. LPA discussed with ADM hospice waiver requirement, housekeeping and record maintenance.

Deficiency is being cited during today's visit per California Code of Regulation (CCR) Title 22, article 87632 (a).See LIC 809D. An exit interview was conducted with ADM Elizabeth Bautista. A copy of the report and appeals rights were provided.

Due to technical difficulty, LIC 809C did not save.
*due to technical difficulty while saving the document the ADMs signature was not captured.

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end of report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2024 09:45 PM - It Cannot Be Edited


Created By: Maria Partoza On 07/30/2024 at 08:43 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: HANSELL VILLA
FACILITY NUMBER: 435202862

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87632(a)
87632 (a)In order to accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee
shall have obtained a facility hospice care waiver from the Department.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not submitting a request for a hospice waiver for R1. ADM assumed that the old waiver for the previous facility (435202377) will automatically be transferred to the new license, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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ADM stated he/she will resubmit the request that was submitted to CDSS on 11/28/2021, prior to being licensed on
7/22/2022 and will be submitted by the POC due date.
Type A
Section Cited
CCR
87405(d)(2)
87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections
87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply:
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview. ADM did not conform to the applicable laws, rules and regulation by not submitting a waiver request prior to accepting R1 for hospice care, which pose/poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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ADM stated that he/she will submit a waiver request with appropriate supporting documents by the POC due date to conform to the rules and regulations based on CCR Title 22.
*Due to tehcnical difficulty, the original LIC809D signed by ADM did not save. See LIC 809C for PDF file of the signed document.
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
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
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