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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440703228
Report Date: 05/22/2024
Date Signed: 05/22/2024 03:19:04 PM


Document Has Been Signed on 05/22/2024 03:19 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:HANOVER GUEST HOMEFACILITY NUMBER:
440703228
ADMINISTRATOR:MARSHA BELLEZAFACILITY TYPE:
740
ADDRESS:813 HANOVER STREETTELEPHONE:
(831) 426-0618
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:15CENSUS: DATE:
05/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Marsha BellezaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to open a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrator Marsha Belleza

LPA entered the facility and asked the staff members their names to cross reference the facility personnel report summary (LIS536), dated May 22, 2024. Staff S1 is not associated to the facility. LPA reviewed S1's name in guardian and S1 is not fingerprint cleared. ADM asked S1 to leave the facility as she is not finger print clear. Staff S1 stated she has been working at the facility for 1 month as kitchen staff and caregiver when needed. Staff S2 is not associated with the facility. S2 stated she has been working at the facility for 9 years.

While investigating the complaint (26-AS-20240514090217) dated May 14, 2024, LPA requested to review R1 and R2's physicians report. R1's physician's report states R1 has dementia. ADM stated the physicians report that they have is from when R1 moved to the facility back in 2015. ADM stated she has not updated R1's physicians report. R2's Physicians Report, dated June 2, 2020 states R2 has dementia. ADM stated she has not updated R2's physicians report.

LPA requested to review R1 and R2's needs and services plan. R1's needs and services plan is dated September 20, 2017. R1's needs and services plan does not address R1's hoarding toilet paper behavior. LPA requested to review R2's needs and services plan. ADM stated she does not have a needs and services plan for R2. During interview with ADM, ADM stated R2 had wandering behavior.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
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 4


Document Has Been Signed on 07/18/2024 10:13 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/18/2024 08:09 AM

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: HANOVER GUEST HOME
FACILITY NUMBER: 440703228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/29/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance (e)(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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ADM stated she will associate S2 to the facility. ADM stated she will send a written plan of action on how she will ensure staff are associated to the facility. ADM stated she will send this written plan of action by POC date.
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Based on interview, observation and record review S2 works in the facility without association which poses an immediate health, safety and personal rights risk to persons in care.
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Type B
05/29/2024
Section Cited
CCR87705(c)(5)

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87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment ... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by;
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ADM stated she will send a written plan of action on how she will ensure residents with dementia have their annual medical assessment and their reappraisal done annually. ADM stated she will send this written plan of action by POC date.
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Based on record review and interview, both R1 and R2's physicians reports and needs and services plans have not been updated annually. Both R1 and R2 have dementia. This poses/posed a potential health, safety or personal rights risk to persons in care.
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ADM stated she will send R1 and R2's the updated physicians reports and needs and services plans, with the responsible party's signature once they have been completed.
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: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 05/22/2024 03:19 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: HANOVER GUEST HOME
FACILITY NUMBER: 440703228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2024
Section Cited
CCR
87355(e)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility.
This requirement was not met as evidenced by;
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ADM asked S1 to leave the faciltiy. ADM stated S1 is going to get his/her finger prints done. ADM stated she will send a plan of action on how she will ensure all staff are finger print cleared beofre working at the facility.
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Based on interview, observation and record review S1 was working in the facility without obtaining a criminal record background clearance which poses an immediate health, safety and personal rights risk to persons in care.
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Type A
05/23/2024
Section Cited
CCR87405(d)

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Administrator Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)....

This requirement is not met as evidenced by:
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ADM stated she will send a written letter of understanding regarding the regulation. ADM stated she will send the letter of understanding by POC date.
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Based on the result of todays visit, the ADM did not conform to applicable laws, rules and regulations. Staff S1 was working at the facility without finger print cleareance. Residents R1 and R2 did not have an updated needs and services plan and physicans report.
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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: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: HANOVER GUEST HOME
FACILITY NUMBER: 440703228
VISIT DATE: 05/22/2024
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Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S1 working in the facility without receiving a criminal record background clearance. Another civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S2 working and residing in the facility without association. See LIC421BG.

This report was reviewed with Administrator Marsha Belleza and a copy of the report and appeal rights were provided.

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END OF REPORT.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4