435294300-4-5-2024-26-AS-MPAA-D42KX6-20240405081700

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294300
Report Date: 04/03/2024
Date Signed: 04/05/2024 08:17:51 AM

Document Has Been Signed on 04/05/2024 08:17 AM - 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:	APRIL GARDEN VILLA OF SARATOGA		FACILITY NUMBER:	435294300
ADMINISTRATOR:	TAN, THELMA		FACILITY TYPE:	740
ADDRESS:	12226 PLUMAS DRIVE		TELEPHONE:	(408) 777-8043
CITY:	SARATOGA	STATE: CA	ZIP CODE:	95070
CAPACITY:	5	CENSUS: 3	DATE:	04/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Thelma Tan		TIME COMPLETED:	01:50 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 4/3/2024 at 10:00 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual required inspection. LPA met with Thelma Tan, Administrator (ADM) and stated the purpose of the visit. At 10:20 LPA conducted the records review first and then LPA toured the facility inside and outside including the bedrooms, bathrooms, kitchen, and living room area. Bedrooms were observed with appropriate furniture and in good repair. Bathrooms are equipped with grab bars and nonskid floor mats. Facility is equipped with comfortable lighting. Facility temperature was maintained at 70 degrees Fahrenheit. Hot water temperature is maintained at 107.7 to 118.7 degree Fahrenheit. Hygiene items, toiletries, and linens were available to the residents. Centrally stored medications, sharp objects, and toxins were locked and inaccessible to the residents. Kitchen area was observed clean and sanitary. LPA observed 2 days’ worth of perishables and 7 days’ worth of nonperishable food. Facility is equipped with smoke detectors and carbon monoxide detectors. Hallways and passageways were free of obstruction. Centrally stored medications were reviewed with medication log were inspected and reviewed.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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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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: APRIL GARDEN VILLA OF SARATOGA	FACILITY NUMBER: 435294300
	VISIT DATE: 04/03/2024

NARRATIVE

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Staff records were reviewed and observed the following; 3 out of 3 staff record has personnel record, criminal record statement, and current first aid certificate. 2 out of 3 staff records were missing the medical training record, 1 out of 3 staff record is missing the health screening and TB clearance. ADM stated some of the records were damaged during the heavy rain and will have the records completed.

Resident records have the following admission agreement, medical assessment with TB test information, updated needs and services plan, and personal rights.

The facility does not have disaster preparedness training on record to meet the overall health, safety and care needs of persons in care. ADM stated that the facility last administered disaster training was from May of 2023.

The following forms to be updated and submitted to CCL by 4/15/2024
LIC 500 Personnel Record
LIC 610E Emergency Disaster Plan
Limited Liability Insurance

Advisory notes were given and deficiencies are issued during today's visit per California Code of Regulations (CCR) Title 22. An exit interview was conducted with administrator Thelma Tan. A copy of the signed report and appeals rights were provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/05/2024 08:17 AM - 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: APRIL GARDEN VILLA OF SARATOGA	FACILITY NUMBER: 435294300
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(b)

Other Provisions

(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff. ADM did not provide training to 2 out of 3 staff since 2017. ADM did not have the most current training on file for 2 out of 3 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2024
	Plan of Correction
1 2 3 4	ADM stated that a training will be provided per title 22 and the number of hours willl be on their training sheet and will provide proof of training to LPA on or before the due date of 5/13/2024

Type B

Section Cited

CCR

87705(c)(3)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above ADM did not conduct, fire and earthquake drills at least once every three months, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2024
	Plan of Correction
1 2 3 4	ADM stated that she will conduct disaster training to ensure the safety of residents and staff. ADM will provide the proof of training to LPA on or before the due date of 5/13/2024.

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	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC809 (FAS) - (06/04)

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