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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294110
Report Date: 07/03/2024
Date Signed: 07/03/2024 01:22:40 PM

Document Has Been Signed on 07/03/2024 01:22 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:WISTERIA HOMEFACILITY NUMBER:
435294110
ADMINISTRATOR/
DIRECTOR:		REGALA, VICTORIA A.FACILITY TYPE:
740
ADDRESS:1160 REGIA CT.TELEPHONE:
(408) 230-1909
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 6CENSUS: 5DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:23 AM
MET WITH:Administrator Victoria RegalaTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Victoria Regala. During the visit, LPA observed 5 residents and 2 staff.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 5 residents bedrooms. The front yard and backyard were inspected. LPA observed two storage sheds in the backyard, being used for storage. LPA observed the garage being used as a storage area. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 82 degrees F, and hot water temperature was measured at 118 degrees F in both resident bathrooms.

Fire extinguisher was serviced in April 26, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on May 9, 2024.

LPA reviewed facility records for 2 staff. LPA reviewed 3 resident records. During a review of R2's records, LPA observed resident R2 has a neruocognetive disorder. R2's physicians report is dated July 1, 2021. R2's needs and services plan is dated Mach 26, 2023. ADM stated she does not have an updated needs & services plan or physicians report for R2. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 2 residents.

Deficiencies are being cited during today's visit, see LIC809-D. This report was reviewed with Administrator Victoria Regala and a copy of the signed report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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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Document Has Been Signed on 07/03/2024 01:22 PM - It Cannot Be Edited


Created By: Manuel Monter On 07/03/2024 at 01:00 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: WISTERIA HOME
FACILITY NUMBER: 435294110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Resident R2 has a neruocognetive disorder. R2's physicians report is dated July 1, 2021. R2's needs and services plan is dated Mach 26, 2023. ADM stated she does not have an updated physicans report or needs and services plan. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the letter of understanding by POC date, July 10, 2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024


LIC809 (FAS) - (06/04)
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