435202874-8-1-2023-26-AS-CDOS-CUAU4T-20230801151539

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202874
Report Date: 08/01/2023
Date Signed: 08/01/2023 03:15:44 PM

Document Has Been Signed on 08/01/2023 03:15 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:	MORNINGSTAR MEMORY CARE AT SAN TOMAS		FACILITY NUMBER:	435202874
ADMINISTRATOR:	GASGONIA, MARK T.		FACILITY TYPE:	740
ADDRESS:	3930 WILLIAMS RD		TELEPHONE:	(669) 201-2015
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	82	CENSUS: 19	DATE:	08/01/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Ignacio Lopez		TIME COMPLETED:	03:20 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 a case manager – incident visit. LPA met with Executive Director (ED) Ignacio Lopez. On 07/19/2023, the Department received an incident report for resident (R1). On 07/04/2023, staff (S2) attempted to redirect R1 out of the kitchenette area and R1 became agitated. Staff (S1) attempted to assist in redirection and R1 became more combative. During the incident, it was observed by staff (S3) that S1 pinched R1’s nose. S1 stated it was because R1 bit him/her. During visit, LPA interviewed 3 staff members and 2 witnesses. Based on interview, it was observed S1 pinched and twisted R1’s nose. It was observed R1 had bleeding on the nose due to a scratch. 2 out of 2 staff state there was no observation R1 had bit S1’s finger nor any indication of a bite mark. The incident was reported to the facility management and placed S1 on leave during an internal investigation. On 07/16/2023, S1 was terminated from the facility. After the incident, the facility notified R1’s physician, notified R1’s family, and conducted an in-service training on topics to include but not limited to resident risks, radiance introduction, observation, protocol for change of conditions, mandatory reporting, incident reporting and investigations, and preventing/recognizing/reporting abuse. ED states the training on proper re-directions were covered during the training. Based on interview and record review, the ED faxed the incident report and SOC341 to the Department on 07/10/2023. The facility received a fax cover sheet with the note of “memory busy”. 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: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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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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: MORNINGSTAR MEMORY CARE AT SAN TOMAS	FACILITY NUMBER: 435202874
	VISIT DATE: 08/01/2023

NARRATIVE

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The ED denied notifying the Department of the incident via telephone nor attempted to re-send the incident report through another mean. The incident report and SOC341 was re-faxed successfully to the Department on 07/19/2023. LPA advised the ED and provided an alternative method to submit incident reports going forward.

During visit, it was observed staff members were not associated to the facility. The facility was licensed as of 06/13/2023. LPA showed the facility’s personnel summary to the ED. The ED stated the individuals listed on the personnel summary work in the home office. The ED stated the staff obtains criminal record clearance as they are staff who also work at another licensed facility under the Licensee. The ED states to have assumed all personnel were transferred from the other care facility during the pre-licensing application process. LPA advised the ED and ED stated understanding. ED attempted to associate staff via Guardian, however, encountered technical difficulties. The ED began filling out the LIC9182s to associate staff members to the facility. The ED states to complete the forms and to submit them to the Department, ASAP.

A deficiency is being cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Executive Director, Ignacio Lopez and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/01/2023 03:15 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: MORNINGSTAR MEMORY CARE AT SAN TOMAS	FACILITY NUMBER: 435202874
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 08/02/2023 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a statement of understanding of Title 22 Section 87211 to LPA Dolores via email by POC due date.
	8 9 10 11 12 13 14	Based on interview, record review, and observation the licensee did not inform the Department of an incident within seven days of the occurrence of the event which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

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