435294334-12-21-2024-26-AS-MMOR-DC6S6W-20241221123636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294334
Report Date: 12/21/2024
Date Signed: 12/21/2024 12:36:49 PM

Document Has Been Signed on 12/21/2024 12:36 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 #3		FACILITY NUMBER:	435294334
ADMINISTRATOR/ DIRECTOR:	CORTES, LEILANI F.		FACILITY TYPE:	740
ADDRESS:	312 LOWELL DRIVE		TELEPHONE:	(408) 504-1809
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Staff Concordia Casabar		TIME VISIT/ INSPECTION COMPLETED:	12:40 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	Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff (S1), Concordia Casabar. During the visit, LPA observed 5 residents and 2 staff. LPA explained the purpose of the visit. Staff S1 contacted ADM and informed her about LPA's visit. ADM stated she could not come to the facility and Staff S1 could sign on her behalf. LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 3 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. While touring bedroom #3, LPA observed wheel chairs obstructing Exit#2. LPA also observed a stick, in the pathway of the sliding screen door, preventing the sliding screen door from opening. (Photographs were taken.) ADM stated the staff may have put the stick there for safety and forgot to remove it. Staff S1 removed the obstructions during LPA's visit. While touring the backyard, LPA observed the fence near exit #2 was partially leaning. LPA also observed the fence next to exit #2 had a section, leading to the front of the home, that had sections of the fence that had wooden planks missing. (Photographs were taken.) LPA also observed the hand rails of the wooden deck had sections that were splintering and had sections that had moss growing. (Photographs were taken.) LPA also observed the metal white sections of the wooden deck was rusting. LPA also observed the wall next to the hose, directly next to exit number 4 has an orange color on the wall. (Photographs were taken.) While touring bathroom #3, LPA observed the shower's wall mount soap dish fixture had tape covering, which was being used to cover the damaged. (Photograph was taken.) Page 1 Out of 2.

Romeo Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 12/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

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 5

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 #3	FACILITY NUMBER: 435294334
	VISIT DATE: 12/21/2024

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
26
27
28
29
30
31
32

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 116 degrees F.

Fire extinguisher was serviced in January 5, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit. The facility's last fire/earthquake drill conducted was on May 14, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA requested to review R1 and R2's needs and services Plans. ADM stated if the forms are not in the file, then she didn't do them.

LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 residents.

LPA requested copies of the following updated documents;
1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. LIC200, please update (i.e., new phone numbers etc), if necessary.
6. Qualifications of Administrator (Certificate)
7. Please review your facility program for updates (incorporating new laws and/or regulations)

LPA provided ADM with CDSS Flyer, "Important updates to Dementia Care and Miscellaneous Changes, effective January 1, 2025."

Deficiencies are being cited during today's visit. This report was reviewed with Staff Concordia Casabar and a copy of the signed report was provided. Appeal rights were provided.

Page 2 Out of 2. END OF REPORT.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 12/21/2024 12:36 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 #3	FACILITY NUMBER: 435294334
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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. While touring bedroom #3, LPA observed wheel chairs obstructing Exit#2. LPA also observed a stick, in the pathway of the sliding screen door, preventing the sliding screen door from opening. ADM stated the staff may have put the stick there for safety and forgot to remove it. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/22/2024
	Plan of Correction
1 2 3 4	ADM stated she will send LPA a letter of understanding regarding the regulation, and the importance of ensuring there are no obstructions to exits and passageways. Staff removed the wheel chairs and stick during visit. ADM stated she will send the plan of correction to LPA by POC date, December 22, 2024.

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.

Romeo Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 12/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 12/21/2024 12:36 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 #3	FACILITY NUMBER: 435294334
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

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. 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. LPA observed the following was in disrepair: the fence next to exit #2, the hand rails of the wooden deck, the white metal sections of the wooden deck, and the orange stained wall next to exit #4. LPA also observed bathroom #3's wall mount shop dish fixture was damaged and had tape covering it. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2024
	Plan of Correction
1 2 3 4	ADM stated she will send a written plan of action on how she will ensure the facility shall be clean, safe, sanitary and in good repair at all times. ADM stated she will send photo documentation showing the issues noted above have been addressed. ADM stated she will send the plan of correction by POC date, December 28, 2024.

Section Cited

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. LPA requested to review R1 and R2's needs and services Plans. ADM stated if the forms are not in the file, then she didn't do them. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2024
	Plan of Correction
1 2 3 4	ADM stated she will send LPA a letter of understanding regarding the regulation. ADM stated she will send a copy of R1 and R2's needs and services plan to LPA by POC date, 12/28/2024.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Romeo Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 12/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 12/21/2024 12:36 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 #3	FACILITY NUMBER: 435294334
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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. The facility's last fire/earthquake drill conducted was on May 14, 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2024
	Plan of Correction
1 2 3 4	ADM stated she will conduct an earthquake/fire drill and send LPA documentation that a drill had taken place. ADM stated she will also send a letter of understanding regarding the regulation and the importance of conducting a drill at least quarterly. ADM stated she will send the plan of correction by POC date, December 28, 2024.

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.

Romeo Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 12/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

LIC809 (FAS) - (06/04)

Page: 5 of 5