435294345-5-22-2023-26-AS-CDOS-CS42UR-20230522174245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294345
Report Date: 05/22/2023
Date Signed: 05/22/2023 05:42:59 PM

Document Has Been Signed on 05/22/2023 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:	WESTMONT OF MORGAN HILL		FACILITY NUMBER:	435294345
ADMINISTRATOR:	JOLIE HIGGINS		FACILITY TYPE:	740
ADDRESS:	1160 COCHRANE RD		TELEPHONE:	(408) 779-8490
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	112	CENSUS: 69	DATE:	05/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Jolie Higgins		TIME COMPLETED:	05:50 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	Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection. LPA met with Executive Director (ED) Jolie Higgins. During visit, LPA toured the facility with ED to include the entrance, dining room, kitchen, memory care, assisted living, hallways, and office spaces. Facility temperature maintained between 71 - 72 degrees Fahrenheit. Fireplace observed adequately screened at the entrance. Facility's license is posted in the hallway. Posters such as the Ombudsman, if you see something say something, emergency disaster plan, and personal rights poster posted in the hallway. Facility kitchen observed clean and sanitary. Facility has an adequate amount of dishes and silverware. Sinks observed with hygiene products and hand washing signs. Special diet paperwork posted in a visible area. Facility observed with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator maintained at 33 degrees Fahrenheit. LPA observed food items in the refrigerator were not properly covered to include a whole container of lettuce and deli turkey meat. The freezer's temperature states the temperature is maintained at 9 degrees Fahrenheit. ED states they have contacted the contractor for the freezer to adjust the thermometer. Fire extinguisher in the kitchen last serviced on 05/13/2022. The facility is scheduled to service their fire extinguishes on 05/31/2023. LPA entered Compass Rose (memory care) with the ED. LPA inspected room 138 and observed cleaning supplies and laundry detergent accessible to 2 out of 2 residents living inside the apartment. The cleaning supplies and laundry detergent were removed from the apartment. LPA inspected room 126, 129, and 121B; each room contained proper furniture, lighting, and linens. Sharp objects and chemicals observed secured. LPA observed residents attending an activity in the dining room. LPA did not observed a planned activities calendar was posted. The compass rose kitchen refrigerator contained an uncovered pitcher of an unknown liquid substance. ED stated the substance smelled like apple juice and was immediately thrown out. SEE LIC809-C.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

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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Document Has Been Signed on 05/22/2023 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: WESTMONT OF MORGAN HILL	FACILITY NUMBER: 435294345
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(23)

General Food Service Requirements

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the facility's refridgerator contained food items such as lettuce, deli turkey meat, and pitcher of a liquid substance that were uncovered which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Licensee will conduct an in-service training with staff. Licensee will submit a written plan to conduct an in-service training for staff to LPA via email by POC due date.

Type A

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the compass rose (memory care) medication room did not properly maintain residents (R1 - R3) centrally stored medication records which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Licensee will conduct an in-service training with compass rose MedTechs. Licensee will submit compass rose medtech in-service training to LPA via email by POC due date. Licensee will also submit a written plan to audit the compass rose medication room to LPA via email by POC due date.

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: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/22/2023 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: WESTMONT OF MORGAN HILL	FACILITY NUMBER: 435294345
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review it was observed residents (R1 - R2)'s apartment in Compass Rose (memory care) contained accessible cleaning supplies and laundry detergent which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Licensee will go through every apartment in compass rose to ensure they have a lock on their cabinets. Licensee will submit their written plan to ensure compliance of section 87309(a) to LPA via email by 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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

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: WESTMONT OF MORGAN HILL	FACILITY NUMBER: 435294345
	VISIT DATE: 05/22/2023

NARRATIVE

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The compass rose exterior passageways was free and clear of obstruction. LPA inspected the exterior's 2 delayed egress doors with ED. LPA and ED observed 1 out of 2 delayed egress doors did not alarm and unable to open. During visit, the facilities maintenance director fixed the delayed egress door and LPA observed the door alarmed and properly open. LPA entered the compass rose medication room and inspected 3 residents (R1 - R3)'s files to include their physician's report, TB, appraisal needs and services plan, consent to treat, and centrally stored medication records. LPA observed the centrally stored medication records were not being maintained to include incomplete and/or inaccurate items such as start dates, refills, instructions, and prescription numbers. LPA observed at least 4 medications of R3's were not written in the centrally stored medication record.

LPA entered the Assisted Living area with the ED. LPA observed an activities calendar posted in the common area. LPA entered rooms 225, 229, 235, 244, and 247. LPA interviewed 5 residents (R4 - R9). LPA entered the AL medication room and reviewed resident R4 - R9's files. R4 - R5 are not on medication management. 2 random residents (R10 - R11) centrally stored medication records were inspected to be maintained.

Staff files observed to include training, CPR certification, medical assessments, fingerprint clearance, and employee rights forms. All staff observed are fingerprint cleared and associated to the facility. Emergency fire drill and elopement drills conducted every month with staff on every shift. Facility is equipped with a carbon monoxide and fire extinguishers throughout the facility.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with the Executive Director (ED), Jolie Higgins and Resident Service Director, Ria Hernandez and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

LIC809 (FAS) - (06/04)

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