435294181-4-2-2021-26-AS-SYIP-BZTUV5-20210406155430

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294181
Report Date: 04/01/2021
Date Signed: 04/02/2021 11:56:15 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/24/2021 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210324145522

FACILITY NAME:	PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2		FACILITY NUMBER:	435294181
ADMINISTRATOR:	CORTES, LEILANI F.		FACILITY TYPE:	740
ADDRESS:	2575 FOREST AVENUE		TELEPHONE:	(408) 985-1982
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	6	CENSUS: 5	DATE:	04/01/2021
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Leilani Cortes		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Facility has rodents and pests

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an initial investigation tele-visit. Due to current COVID-19 situation, LPA virtually met with the Licensee Leilani Cortes using Zoom software.

LPA virtually toured the facility, interviewed 3 residents, and 4 staff.

On 04/01/2021, LPA interviewed 3 residents, 1 out of 3 residents stated a rodent was seen in the facility.

On 04/01/2021, LPA interviewed 4 staff, 2 out of 4 staff stated they saw a rodent in the facility. 1 rodent was captured, no more rodent had been observed since.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210324145522

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2	FACILITY NUMBER: 435294181
	VISIT DATE: 04/01/2021

NARRATIVE

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On 04/01/2021, LPA did not observe any droppings or rodent during the virtual tour. LPA observed a rodent trap was in the kitchen.

Based on interviews, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED, which means that the allegation did occur.

A deficiency was cited today as per California Code of Regulations, Title 22. See 9099-D for more information.

This report was reviewed with Licensee and a copy of this report was emailed for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210324145522

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2	FACILITY NUMBER: 435294181
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/15/2021 Section Cited HSC 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Licensee already set up a rodent trap. 1 rodent was captured, no more rodent had been observed since. Licensee was to keep monitoring the situation.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews, there was rodent in the facility. This posed a potential health and safety risk to residents 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: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

LIC9099 (FAS) - (06/04)

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