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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294155
Report Date: 07/02/2024
Date Signed: 07/02/2024 04:42:52 PM

Document Has Been Signed on 07/02/2024 04:42 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:ST. ANNE'S HOME FOR ELDERLYFACILITY NUMBER:
435294155
ADMINISTRATOR/
DIRECTOR:		BANAAG M., MANALO MAYLENEFACILITY TYPE:
740
ADDRESS:790 LAKEBIRD DRIVETELEPHONE:
(408) 744-1752
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY: 6CENSUS: 5DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Maylene ManaloTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Maylene Manalo. During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the locked storage areas for medications, sharp objects, and cleaning supplies. The first aid kit was observed and found to be complete.

LPA toured 5 out of 5 resident bedrooms and observed each bedroom to have working lights and available bedding and clothing storage areas. LPA Marrufo tested the smoke detectors in the living room, hallway, and 5 out of 5 resident rooms. A smoke detector in one of the bedrooms had a very faint sound. The smoke detector in the living room had a constant chirping sound during visit. The rest of the smoke detectors functioned properly when tested. LPA Marrufo tested one out of one carbon monoxide detector and it functioned properly when tested.

LPA toured the outside area and found the outdoor exit to be clear of obstructions. LPA Marrufo reviewed 4 out of 4 resident Centrally Stored Medication and Destruction Records (CSMDR). One resident does not take medications. Resident R1 was missing 3 medications in the CSMDR and resident R2 was missing 2 medications in the CSMDR. LPA reviewed 5 out of 5 resident records. Resident R1 was missing an Appraisal/Needs and Services Plan. R2's record was missing an Appraisal/Needs and Safeguard for Property and Valuables (SPV) form. Resident R3 was missing an Emergency Contact and Information Form, Appraisal/Needs and Services Plan, SPV, and LIC613C Personal Rights form. LPA Marrufo reviewed 2 out of 2 staff records and found them to be complete. Advisory Notes were issued. See LIC9102 for more information. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with Maylene Manalo and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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 is an Amendment of Original Document on 07/31/2024 02:28 PM


Created By: David Marrufo On 07/02/2024 at 04:19 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. ANNE'S HOME FOR ELDERLY
FACILITY NUMBER: 435294155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)(1)-(4)
87465 Incidental Medical and Dental Care: e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (1) The specific symptoms which indicate the need for the use of the medication. (2) The exact dosage. (3) The minimum number of hours between doses. (4) The maximum number of doses allowed in each 24-hour period. This requirement is not met as evidenced by:
Deficient Practice Statement
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*Amended on 08/01/2024 to provide more detail to the Deficient Practice Statement * Based on record review, the licensee did not comply with the section cited above in 2 out of 4 Centrally Stored Medication and Destruction Records, which poses a potential health risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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Licensee agrees to audit all resident Centrally Stored Medication and Destruction Record and ensure that all prescription and nonprescription PRN medications have been entered into each resident's Centrally Stored Medication and Destruction Record and then submit a statement of completion by POC date to CCL.
Type B
Section Cited
CCR
87506(b)(16)
87506 Resident Records (b) Each resident’s record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 2 out of 5 resident records which were missing the Safeguard for Property and Valuables form, which poses/posed a potential personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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Licensee agrees to submit copies of the Safeguard for Property and Valuables form for the two residents who were misisng those forms to CCL by POC date.
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
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
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