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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294181
Report Date: 05/08/2024
Date Signed: 05/08/2024 05:42:55 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/08/2024 05:42 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:PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2FACILITY NUMBER:
435294181
ADMINISTRATOR:CORTES, LEILANI F.FACILITY TYPE:
740
ADDRESS:2575 FOREST AVENUETELEPHONE:
(408) 985-1982
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:6CENSUS: 6DATE:
05/08/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lead Staff, Mary Ann VillanuevaTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to continue the annual inspection from 5/2/2024. LPA Rai met with Lead Staff (LS) Mary Ann Villanueva. LPA Rai observed 2 staff and 6 residents at the facility. At this time, the facility has 2 hospice residents.

During today's visit, LPA Rai followed up with 2 staff files. On 5/2/2024, LPA Rai reviewed 1 staff file for S1 where first aid training was expired. During today's visit, LPA Rai observed S1's first aid training was completed on 5/3/2024. On 5/2/2024, LPA Rai reviewed staff file for S2 where S2's Tuberculosis (TB) test was not included in the health screening and a separate TB test results were not found in the file. During today's visit, LPA Rai observed S2's TB test result in the file with a note stating the new records were from another facility the Licensee currently manages along with this current facility.

During today's visit, LPA Rai reviewed 2 resident files who are not on hospice services. LPA Rai observed R1-R2''s file did not contain the Appraisal/Needs and Services Plan. R2's file did not contain a signed order for half-side rails attached to R2's bed and LS clarified R2 is not on hospice services. R2's file did contain an Admission Agreement but it's not for this current facility.

LPA Rai observed the water temperature in the bathroom sinks ranged from 118.4 degrees Fahrenheit - 119.3 degrees Fahrenheit. The water temperature in the kitchen sink was 118.9 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 4/5/2024. LPA Rai observe the thermometer in the freezer was measured at 0 degrees Fahrenheit and the thermometer in the fridge was measured at 40 degrees Fahrenheit.

Continuation on LIC 809-C, Page 1 of 3.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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 9


Document Has Been Signed on 05/08/2024 05:42 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: PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2
FACILITY NUMBER: 435294181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
87411(c)(1)

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87411 Personnel Requirements - General (c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement was not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure staff who provide care to residents receive first aid training before certification expires. The written plan is due by POC due date. Licensee/Administrator agreed and understood.
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Based on record review and interview, S1's file did not contain first aid training on 5/2/2024 and S1 provides direct care to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
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During today's visit, LPA Rai observed S1's file contained first aid training which was conducted on 5/3/2024.
Type B
05/15/2024
Section Cited
CCR87412(a)

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87412 Personnel Records (a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.

This requirement was not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure staff files are maintained at the facility by POC due date. Licensee/Administrator agreed and understood.
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Based on record review and interview, S2's file did not contain TB test results with the health screening and on 5/2/2024 staff file was incomplete at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
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During today's visit, LPA Rai observed S2's file contained the TB test result.
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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9


Document Has Been Signed on 05/08/2024 05:42 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: PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2
FACILITY NUMBER: 435294181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
87463(a)

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87463 Reappraisals (a) The pre-admission appraisal shall be updated...The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
This requirement was not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure R1 and R2 have completed Appraisal/Needs and Services Plan in resident's file by POC due date. Licensee/Administrator agreed and understood.
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Based on record review, 2 out of 2 resident files (R1-R2) did not contain Appraisal/Needs and Services Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
05/15/2024
Section Cited
CCR87608(a)(5)(A)

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87608 Postural Supports (a)(5)(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure physician's order for half-bed rail is in R2's resident file by POC due date. Licensee/Administrator agreed and understood.
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Based on record review, 1 ouf of 2 resident files (R2) did not contain a physician's order to use half-bed rail for mobility and R2 is not receiving hospice services which poses/posed a potential 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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 05/08/2024 05:42 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: PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2
FACILITY NUMBER: 435294181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2024
Section Cited
CCR
87465(h)(5)

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87465 Incidental Medical and Dental Care (h) (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement was not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure medications are stored in its original container by POC due date. Licensee/Administrator agreed and understood.
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Based on recored review, observation and interview,LPA Rai osberved a medication bottle containing two different types of medication different than the one on the bottle label which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
05/09/2024
Section Cited
CCR87411(a)

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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure staff receive medication training by POC due date. Licensee/Administrator agreed and understood.
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Based on record review, interview and observation R1's 1 out of 3 meds not administered to R1 as prescribed by the MD and R2's 4 out of 4 meds were not administered to R2 as prescribed by the MD which poses 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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 05/08/2024 05:42 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: PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2
FACILITY NUMBER: 435294181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2024
Section Cited
CCR
87207

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87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure staff are trained in accurate record keeping which reflects the medication administed to the residents in care by POC due date. Licensee/Administrator agreed and understood.
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Based on record review, interview and observation, R1-R2 e MARs noted medications administered but LS stated R1 requested for PRN medication and R2 refused medication, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
05/09/2024
Section Cited
CCR87405(d)

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
This requirement is not met ad evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation by POC due date. Licensee/Administrator agreed and understood.
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Based on interview, record review and observation, ADM did not adequate provide attention to the management & administration of the facility by conforming to the applicable laws, rules and regulations which poses/posed an immediate Health, Safety, or Personal Rights
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(con't)
risk to persons in care.
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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 05/08/2024 05:42 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: PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2
FACILITY NUMBER: 435294181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
87465(h)(6)

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87465 Incidental Medical and Dental Care (h)(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes.
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure Centrally Stored Medication Record is accurate and maintained for R2 by POC due date. Licensee/Administrator agreed and understood.
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Based on interview and record review, R2's Centrally Stored Medication Record is not accurate as stated by Lead Staff (LS). LS stated R2's medication was started on 4/10/2024, when the log states 4/9/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
05/15/2024
Section Cited
CCR87565(b)

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87465 Incidental Medical and Dental Care (b)If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication...
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure resident file is complete with necessary documents from physician to administer PRN medication by POC due date. Licensee/Administrator agreed and understood.
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Based on record review, R2's physician has not stated in writing that the resident is able to determine and communicate his/her need for PRN medication which poses/posed a potential 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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 6 of 9


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: PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2
FACILITY NUMBER: 435294181
VISIT DATE: 05/08/2024
NARRATIVE
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Page 2 of 3.

During today's visit, LPA Rai reviewed 2 resident medications and central stored medication records for resident R1 and R2. For R1, 1 out of 3 medications were not given as prescribed to the resident. Medication #3 was prescribed as 1 tablet 3 times a day as well as PRN as needed. The medication bottle was started on 4/29/2024 and the medication in the bottle when opened were 60 tablets. LPA Rai and LS counted the tablets in medication #3's bottle and observed 27 tablets. LPA Rai observed PRN sheet noted PRN medication was administered on 3/22/2024, prior to this current medication bottle was started. LPA Rai observed there were 3 tablets were missing from bottle. LS stated resident does ask for PRN in the evenings for pain, however, LS stated she did not write the information in the PRN log.
For R2, resident's file does not contain a document where R2's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication. In addition, 4 out of 4 medications were not given as prescribed to the resident. Medication #4 was prescribed as 1 tablet a day and the medication bottle was started on 4/21/2024. It was logged on the Centrally Stored Medication Record (CSMR) as 94 tablets in the bottle when started. LS stated R2's medications came from another facility so LS counted all the medications when R2 was admitted and recorded in on R2' Centrally Stored Medication log. LPA Rai and LS counted the tablets in Medication #4 bottle and observed 71 tablets. LPA Rai observed there were 5 tablets tablets missing from the bottle.
LS looked at medication cabinet and discovered R2's medication bottles that LS stores medication when R2 refused medication. LS provided LPA Rai a medication bottle which was not the original container for medication #4 and contained two different medications. LPA Rai observed 5 tablets matched the color and size of medication #4 and two tablets that were a different size and color. LPA Rai advised LS to keep medications in the prescribed bottles and not to mix medications into a different medication bottle. LS agreed and understood.
Medication #5 was prescribed as 1 tablet given on Monday, Wednesday and Friday and the medication bottle was started on 4/10/2024. It was logged on the CSMR as 100 tablets in the bottle when started. LPA Rai and LS counted the tablets in Medication #5 bottle and observed 89 tablets and there should be 61 tablets in the bottle, LPA Rai observed there were 28 extra tablets in the bottle. LS stated R2 will refused the medication. LS provided the Medication Administration Record, and LPA Rai observed the medication was initialed by LS stating the medication was given to resident as prescribed but there were still 28 tablets extra in the bottle.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9
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: PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2
FACILITY NUMBER: 435294181
VISIT DATE: 05/08/2024
NARRATIVE
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Page 3 of 3.
Medication #6 was prescribed as 1.5 tablets at bedtime. It was logged on the CSMR as 87 tablets in the bottle when started on 4/9/2024. LPA Rai and LS counted the tablets in Medication #6 bottle and observed 44.5 tablet and there should be 43.5 tablets, LPA Rai observed there was 1 extra tablet in the bottle. LS stated R2 will refused the medication. LS provided the Medication Administration Record, and LPA Rai observed the medication was initialed by LS stating the medication was given to resident as prescribed. LS stated R2 will drop the medication on the floor when the room is dark and LS has had to replace the medication and throw the dropped tablet in the trash. LS stated she did not log on the destruction log. LS stated she might have started the medication on 4/10/2024 not as logged on CSMR as 4/9/2024. LPA Rai advised LS to correctly document the CSMR log as accurately as possible.
Medication #7 was prescribed as 1 tablets daily and the medication bottle was started on 4/9/2024. It was logged on the CSMR as 24 tablets in the bottle when started. LPA Rai and LS counted the tablets in Medication #7 bottle and observed 24 tablets and there should be 26 tablets, LPA Rai observed there were 2 missing tablets in the bottle.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs.

Lead Staff attempted to reach Licensee Leilani Cortes over the phone and Licensee was not available and was not present at the other two facilities managed by Licensee.

Exit interview was conducted with Lead Staff, Mary Ann Villanueva. A copy of this report was provided to Lead Caregiver, Mary Ann Villanueva. Appeal Rights were provided.
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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 05/08/2024 05:42 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: PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2
FACILITY NUMBER: 435294181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
87507(a)

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87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure resident's Admission Agreement is accurate to where the resident is currently residing by POC due date. Licensee/Administrator agreed and understood.
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Based on interview and record review, R2's file did contain an Admission Agreement but it was not for the current facility where R2 resides which poses/posed a potential 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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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