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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202871
Report Date: 09/13/2023
Date Signed: 09/13/2023 11:40:05 AM

Document Has Been Signed on 09/13/2023 11:40 AM - 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:SAGEWELL HOMEFACILITY NUMBER:
435202871
ADMINISTRATOR:TRAN, ANTHONYFACILITY TYPE:
735
ADDRESS:5716 SAGEWELL WAYTELEPHONE:
(650) 868-2860
CITY:SAN JOSESTATE: CAZIP CODE:
95138
CAPACITY: 4CENSUS: 4DATE:
09/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:13 AM
MET WITH:Staff Luis LopezTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff member Luis Lopez (S1). S1 called Administrator (ADM) Anthony Tran and ADM stated he was out of town but would give S1 permission to sign on his behalf.

LPA toured the facility inside which included; the Living room, kitchen, dinning room, two restrooms and 3 residents bedrooms, laundry room and the garage. Front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring the facility LPA Monter observed the following toxic/detergents accessible to residents in care. At 8:36am LPA toured the facility laundry room. LPA observed the laundry room door does not have a lock. LPA observed the shelve above the washing machine had laundry detergent. While touring the outside of the facility, at 8:53am, LPA observed a shed without a door. LPA observed paint cans, motor oil inside the shed accessible to residents in care. While measuring bedroom 1's bathroom temperature water at 9:11am, LPA opened the cabinet under the sink and observed "Awesome Carpet cleaner".

While touring the facility, at 8:44am, LPA Monter observed Tylenol in resident bedroom #1. ADM stated the medication most likely belongs to R1, who is staying for respite for SARC. ADM stated that medication should be locked in the locked in the centrally stored medication cabinet.

Fire extinguisher was serviced in April 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last fire drill was on July 5th, 2023.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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 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: SAGEWELL HOME
FACILITY NUMBER: 435202871
VISIT DATE: 09/13/2023
NARRATIVE
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Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degree F. Hot water temperature in hallway bathroom was measured at 116 degrees F and hot water temperature in Bedroom 2's bathroom was measured at 118 degrees F.

LPA asked S1 to review facility records for 2 staff and 2 residents. S1 could not find them. LPA called administrator at 9:56am. ADM stated he was in the process of updating the staff and resident files. ADM stated the files are in his office and he is currently out of town. LPA reviewed 2 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff (S1) and 1 resident. LPA attempted to interview another resident, but they were already headed out the door for day program. ADM stated the facility currently doesn't have P & I but is working with SARC to start that process.

A deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Anthony Tran via phone call. ADM stated S1 could sign on his behalf. Appeal rights were provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/13/2023 11:40 AM - It Cannot Be Edited


Created By: Manuel Monter On 09/13/2023 at 10:57 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: SAGEWELL HOME
FACILITY NUMBER: 435202871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed 3 instances where toxics were acessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2023
Plan of Correction
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2
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4
ADM stated he woul relocated all toxics to a locked area, where they are inacessible to resident in care. ADM stated he will send letter of undertstanding send a letter of understanding regarding Title 22 regulations on storing cleaning products/ toxics and its imporatnce of protecting residents in care. ADM agreed and understood.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(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 is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's obeservation, the licensee did not comply with the section cited above. LPA observed an acsessible bottle of Tylenol in bedroom 1's dresser which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2023
Plan of Correction
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ADM stated he will send letter of undertstanding send a letter of understanding regarding Title 22 regulations on storing medications and its imporatnce of protecting residents in care. ADM agreed and understood.
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: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/13/2023 11:40 AM - It Cannot Be Edited


Created By: Manuel Monter On 09/13/2023 at 10:57 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: SAGEWELL HOME
FACILITY NUMBER: 435202871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview, the licensee did not comply with the section cited above. LPA requested personnel records, but ADM stated they were not in the facility and he was out of town. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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ADM stated he send letter of undertstanding send a letter of understanding regarding Title 22 regulations on personnel records. ADM stated he will send photo showing staff documents are back at the facility. ADM agreed and understood.
Type B
Section Cited
CCR
80070(d)
Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested client records, but ADM stated they were not at the facilty. ADM stated the files were in his office and he was out of town. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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ADM stated he will send letter of undertstanding send a letter of understanding regarding Title 22 regulations on client records and its imporatnce of protecting residents in care. ADM stated he will send photo showing client records are back at the facility. ADM agreed and understood.
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: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
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