445200566-2-8-2024-26-AS-CDOS-D29UAW-20240208142526

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445200566
Report Date: 02/08/2024
Date Signed: 02/08/2024 02:25:34 PM

Document Has Been Signed on 02/08/2024 02:25 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:	MAPLE HOUSE, THE		FACILITY NUMBER:	445200566
ADMINISTRATOR:	CHEN, HONG-GEN		FACILITY TYPE:	740
ADDRESS:	410 PENNSYLVANIA AVENUE		TELEPHONE:	(831) 423-6347
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	22	CENSUS: 10	DATE:	02/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Ann Roxas		TIME COMPLETED:	02:30 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 required - 1 year annual inspection. LPA met with Designated Administrator (ADM), Ann Roxas. During visit , LPA toured the facility with designated ADM to include the living room, dining room, kitchen, resident bedrooms, bathrooms, storage, sun room, backyard, and exterior. LPA observed cameras located in the common areas, kitchen, office space, and exterior. Fireplace observed screened. No open bodies of water observed. All fire exit routes were free and clear of obstruction. Facility temperature maintained at 74 degrees Fahrenheit. Fire extinguisher last services on 06/21/2023. LPA observed the presence of a carbon monoxide detector. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature in the kitchen maintained at 50 degrees Fahrenheit. Items inside the refrigerator were observed covered and labeled. Freezer temperature maintained above 10 degrees Fahrenheit. ADM was advised. Kitchen equipped with utensils, cups, plates, and bowls. Medications, sharp objects, and chemicals observed secured. Resident bedrooms observed well-maintained and equipped with adequate lighting, beds, linens, chair, dressers, and night stands. Bathrooms observed with a lidded trash bin, paper supplies, and hygiene products. Hot water temperature maintained at 118 degrees Fahrenheit. 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: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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: MAPLE HOUSE, THE	FACILITY NUMBER: 445200566
	VISIT DATE: 02/08/2024

NARRATIVE

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LPA reviewed 3 resident files were complete to include a physician's report, TB result, appraisal/needs and services plan, identification/emergency information, personal rights, admission agreement, and safeguard of personal properties and valuables. 3 residents centrally stored medication and centrally stored medication records observed maintained. 2 out of the 3 residents were interviewed.

LPA reviewed 3 staff files were complete to include a health screening, TB result, fingerprint clearance, personnel record, and training documents. Staff are provided annual training on topics to include but not limited to dementia/Alzheimer's, postural supports, restricted health condition, hospice, resident rights, and medications. 3 out of 3 staff were interviewed.

Facility has an updated emergency disaster plan. Emergency drills are being completed quarterly and the last was conducted on December 2023. LPA observed the facility has emergency water and flashlights accessible. Facility has multiple complete first aid kits.

Facility has an updated infection control plan. Staff are trained on infection control. Facility has sufficient amount of PPE supplies. LPA observed the facility has multiple hand sanitizer and PPE supplies throughout the facility.

Posters/signs observed to include but not limited to a 8x10 complaint poster, 20x26 ombudsman poster, personal rights, house rules, facility license, and COVID-19 related posters.

A deficiency was cited per California Code of Regulation, Title 22. See LIC809-D. Advisory note provided. LPA reviewed the deficiency and plan of correction with the Administrator, Hong-Gen Chen over the telephone.

This report was reviewed with Designated Administrator (ADM), Ann Roxas and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/08/2024 02:25 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: MAPLE HOUSE, THE	FACILITY NUMBER: 445200566
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(21)

(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the facility's refrigerator temperature is maintained at 50 degrees Fahrenheit and the freezer temperature maintained above 10 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/09/2024
	Plan of Correction
1 2 3 4	Staff removed food items in the refrigerator and freezer that were blocking the air circulation. Licensee states to have staff check the refrigerator and freezer more often. Licensee will submit a statement of understanding of the section cited above to LPA Dolores 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: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC809 (FAS) - (06/04)

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