435294246-8-8-2024-26-AS-MTAN-D7XT9P-20240808143217

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294246
Report Date: 08/08/2024
Date Signed: 08/08/2024 02:32:27 PM

Document Has Been Signed on 08/08/2024 02:32 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:	SHAMROCK RESIDENTIAL CARE HOME		FACILITY NUMBER:	435294246
ADMINISTRATOR:	ABLAO, VICKY		FACILITY TYPE:	740
ADDRESS:	1025 SHAMROCK DRIVE		TELEPHONE:	(408) 879-9603
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	6	CENSUS: 4	DATE:	08/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Vicky Ablao		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 8/8/2024 at 9:15 a.m. Licensing Program Analysts (LPAs) Marcella Tarin & Maria (Mita) Partoza conducted an unannounced required 1 year Inspection and LPA was greeted by staff upon arrival. Licensee/Administrator, Vicky Ablao arrived shortly thereafter. LPAs stated the purpose of the visit. The facility is an Residential Care Facility serving adults from 60 and over and has hospice wavier for 5, and capacity of 6. At 9:15 a.m. LPAs toured the facility inside and out. Four residents were present and engaged in various activities. The temperature inside the home was at a comfortable 73 degrees F. Residents bedrooms were observed to be sanitary, organized with sufficient storage for resident's personal belongings. LPAs observed working auditory alarm system for each resident's emergency exit doors. Bathrooms were observed to be clean, with grab bars, toilet papers and non-skid mats. Hot water temperature was measured 107.4 degrees F. Living room and activity area, kitchen and dining area were observed to be in order. Cleaning supplies, toxic and sharp objects are secured and inaccessible to residents. 7 days of non-Perishable and 2 days of perishable food supplies were observed. Smoke alarms, carbon monoxide detectors were observed to be in good working condition. The fire extinguishers was last inspected on 3/8/2024. The facility has first aid kit that are accessible to staff. Medications were stored in a locked medication cart. At 10:15 a.m. LPAs discussed with administrator (ADM) maintenance and housekeeping such as changing the bathroom shower liner that was observed to have black residue at the bottom and the cabinet door to the right was loose/coming off the hinge. LPAs observed part of a wooden ramp that has loose planks and loose hand rail posts, which are are not secured to the bottom of the ramp (ramp is located on the exterior of bedroom #1) . LPAs observed missing grout between tiles on the kitchen counter next to the sink where food is prepared, food particles were stuck in between the spaces that could contaminate food served. page 1 of 2 see LIC 809C

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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 3

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: SHAMROCK RESIDENTIAL CARE HOME	FACILITY NUMBER: 435294246
	VISIT DATE: 08/08/2024

NARRATIVE

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Staff records were reviewed to be complete and current with CPR/first aid, clearances and training. Residents records, medications are labeled and log on the Centrally Stored Medication & Destruction Record (CSMDR). Emergency drill is conducted on 1/2024, 4/2024 & 7/2024. ADM stated that fire inspection is conducted yearly to assess the fire sprinkler installed in the facility. The sprinklers were tested on 8/28/2023.

Deficiencies are cited during today's visit based on California Code of Regulations (CCR) Title 22. See LIC 809D. An exit interview was conducted with ADM Vicky Ablao. A copy of the report and appeals rights were provided.

LPAs requested for the following documents and were provided by the administrator.
LIC 500, LIC 308, updated copy of administrator certificate and resident roster. A copy of the liability insurance and the lease agreement.

End of report, Page 2 of 2.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/08/2024 02:32 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: SHAMROCK RESIDENTIAL CARE HOME	FACILITY NUMBER: 435294246
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)(1)

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)... kitchen areas shall be maintained in a clean, sanitary and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above by not maintaining the exterior ramp handrail at bedroom #1 exterior area safe and sturdy. The kitchen surface had food particles stuck in between the tiles that were missing the grout, which can contaminate the food served, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator stated that a plan to schedule a repair for the handrail ramp and to fill in the gaps on the kitchen tille surface will be submitted to LPA by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3