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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202870
Report Date: 01/26/2024
Date Signed: 01/26/2024 03:29:34 PM

Document Has Been Signed on 01/26/2024 03:29 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:DIGNITY CARE HOMEFACILITY NUMBER:
435202870
ADMINISTRATOR:ANN MARIE R ZARRAGAFACILITY TYPE:
735
ADDRESS:3899 MARE PLACE CTTELEPHONE:
(909) 205-0891
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 3DATE:
01/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator Ann Marie R ZarragaTIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit in regards to an incident report the department received on January 16, 2024. LPA met with Administrator (ADM) Administrator Ann Marie R Zarraga and explained the purpose of the visit.

On January 16, 2024, the department received an incident report stating the resident R1 had eloped from the facility. The incident report stated the following; the elopement occurred on January 15, 2024 and at 1:00am, R1 had eloped from the facility. S1 tried to run after R1, but could not keep sight of him/her. S1 contacted 911 because he/she could not find R1. R1 was brought back to the facility at 3:15am.

On January 19, 2024, the department received an incident report stating the resident R1 had eloped from the facility. The incident report stated the following; the elopement occurred on January 19, 2024 and at 4:00am, R1 had eloped from the facility. After 30 minutes of searching, Staff found R1 two blocks away and law enforcement was already there.

Based on a review of R1's Individual Program Plan, dated June 26, 2023, "R1 has limited safety awareness. R1 should not be left unattended... R1 does best with 24/7 supervision to ensure his safety." (Page 3) R1's IPP also states, " Based on Monterey Horsemanship Day Program (MBH)'s assessment, MBH has requested that R1 receive 2 additional staffing supports during day program hours and 1 additional staffing support during transport." (Page 14) During interview with ADM, ADM stated the day R1 moved in, she got the phone number for the day program.

Based on an interview with staff, ADM she was unaware of R1's behaviors would be to this extent. ADM stated when she spoke with Summit, the agency that provides caregivers, the day R1 moved to the facility. ADM stated Summit informed her that they were requesting 2-1 care for R1's previous living home.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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 4
Document Has Been Signed on 01/26/2024 03:29 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/26/2024 at 02:18 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: DIGNITY CARE HOME
FACILITY NUMBER: 435202870

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2024
Section Cited
CCR
80068.3(a)

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80068.3 Modifications to Needs and Services Plan (a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, ... shall be maintained in the client's file. This requirement was not met as evidenced by;
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ADM stated she will send letter of understanding regarding the regulation. ADM stated she will send letter to LPA by POC date, 02/02/2024.
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Based on interview, ADM stated she does not have a needs and services plan for the R1. ADM stated she did not update R1's needs and services plan as well. This poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
02/02/2024
Section Cited
CCR85068.1(b)

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85068.1 Admission Procedures (b) No client may be admitted prior to a determination of the facility's ability to meet the needs of the client, which must include an appraisal of his/her individual service needs as specified in Sections 80068.2 and 85068.2. This requirement was not met as evidenced by;
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ADM stated she will send letter of understanding regarding the regulation. ADM stated she will send letter to LPA by POC date, 02/02/2024.
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Based on records reviewed, the licensee's letter acknowledged R1's IPP states R1 is a elopement risk & acknowledged R1 is not an appropriate placement for the facility. ADM stated the facility had R1's IPP in December 2023. This poses a potential health, safety or 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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/26/2024 03:29 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/26/2024 at 02:35 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: DIGNITY CARE HOME
FACILITY NUMBER: 435202870

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2024
Section Cited
CCR
85078(a)(1)

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85078 Responsibility for Providing Care and Supervision (a)(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by;
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ADM stated she will send letter of understanding regarding the regulation. ADM stated she will send letter to LPA by POC date, 02/02/2024.
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Based on record review, R1 has limited safety awareness and should not be left unattended. ADM acknowledged R1 has left the facility unatteneded on 1/15/2024 and 1/19/2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
02/02/2024
Section Cited
CCR85165(b)

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85165 Emergency Intervention Staff Training (b) Staff who use, participate in, ... of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified ... completed the training. This requirment was not met as evidenced by;
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ADM stated she will send letter of understanding regarding the regulation. ADM stated she will send letter to LPA by POC date, 02/02/2024.
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Based on interview with ADM, S1 did hold R1. Based on interview with S1, S1 stated his/her last training regarding holds was 4-5 years ago. This poses/posed a potential health, safety or 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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024


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: DIGNITY CARE HOME
FACILITY NUMBER: 435202870
VISIT DATE: 01/26/2024
NARRATIVE
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Based on a review of Licensee's letter, dated January 16, 2024, regarding R1, Licensee stated,"R1's IPP clearly states that he/she is at risk of escaping and based on conversations with parents, we have learned that he has disappeared for days at a time."

Based on a review of ADM's email communication with LPA Monter, dated January 16, 2024, ADM stated "R1's real behavior was not disclosed to us before his/her move in thus we were not prepared to give the appropriate care he/she needs...His/her driver for the day program said that R1's behavior of hitting and biting others is constant...R1's His/her former caregivers whom he was already familiar with were also hit and bitten. One even had to be treated for his wound."

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
This report was reviewed with Administrator Ann Marie R Zarraga and a copy of the report was provided. Appeal Rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC809 (FAS) - (06/04)
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