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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202895
Report Date: 02/19/2025
Date Signed: 02/19/2025 04:04:12 PM

Document Has Been Signed on 02/19/2025 04:04 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 ASSISTED LIVING OF WEST SAN JOSEFACILITY NUMBER:
435202895
ADMINISTRATOR/
DIRECTOR:		WELCH, JOYCEFACILITY TYPE:
740
ADDRESS:1380 S DEANZA BLVDTELEPHONE:
(669) 295-6500
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 149CENSUS: 82DATE:
02/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Blyth ObienTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit to follow up with the case management conducted on 1/24/2025, and met with Wellness Director Blyth Obien (BO).

On 1/18/2025, resident R1 was found not in the facility around 12:30PM. From the footage of the surveillance system, resident R1 left the facility without staff knowledge around 12:00PM. Facility staff searched for R1 but were unable to find R1. Facility staff notified R1's family and police. R1 was found on 1/18/2025, at 1:09PM without injury.

Based on the interview with Previous Executive Director (PED), R1 exited from the building exit door #3 which is delayed egress door with 15-20 seconds delay opening mechanism and with alarm, but staff in the memory care unit at that time period did not hear alarm sounded. PED stated this is the first time R1 left the facility without staff knowledge. PED stated there is no police report case number for this incident.

Based on the interview with R1's family (FM), the facility staff notified FM immediately and the facility staff searched eagerly for R1.

Based on the review of R1's physician report dated 12/13/2024 and R1's care plan dated 12/12/2024, R1 has dementia, wandering behavior, and is unable to leave facility unassisted.

Citation noted for today's visit. See LIC809-D.

Exit interview was conducted with BO. The report was provided to BO for review and signature. A copy of the report was provided to BO.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2025
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 2
Document Has Been Signed on 02/19/2025 04:04 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 02/17/2025 at 04:51 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: MORNINGSTAR ASSISTED LIVING OF WEST SAN JOSE
FACILITY NUMBER: 435202895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2025
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by:
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Wellness Director stated to submit a plan of correction by the POC due date to provide the training to staff to provide care and supervision to meet residents' needs and to provide the staff training log.
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Based on interview and record review, Licensee did not provide the necessary care and supervision to meet R1's care needs, which resulted in R1's elopement from the facility on 1/18/2025, which poses/posed an immediate 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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
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