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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202879
Report Date: 01/16/2025
Date Signed: 01/16/2025 04:13:06 PM

Document Has Been Signed on 01/16/2025 04:13 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:RACHELLE'S HOME IIIFACILITY NUMBER:
445202879
ADMINISTRATOR/
DIRECTOR:		ILAGAN, MYLAFACILITY TYPE:
740
ADDRESS:4101 FAIRWAY DRIVETELEPHONE:
(831) 201-4785
CITY:SOQUELSTATE: CAZIP CODE:
95073
CAPACITY: 26CENSUS: DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Myla Ilagan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Myla Ilagan. LPA toured the interior and exterior of the facility with ADM to include the kitchen, office, resident rooms, dining room, bathrooms, back and front of the facility. The facility is a residential care home for the elderly, and consists of two large buildings, Wing A and Wing B. Facility thermostat temperature display was observed at 68 degrees F. All exit and passageways were free and clear of obstruction.

At 9:50 AM LPA toured the Wing B of the facility. LPA observed the facility thermostat temperature display at 68 degrees F. LPA toured 8 resident rooms in Wing B. LPA observed 7 out of 8 resident rooms to have functioning lights, a bed, a dresser/table and storage space for personal belongings. LPA observed 7 out of 8 resident bathrooms had functioning lights, paper towels and hand soap. 7 out of 8 resident bathrooms had no slip-resistant mats on the bathroom floor.

At 9:55AM, during tour of resident rooms, LPA observed a male staff member asleep in an unoccupied bedroom (#18). ADM stated the staff member would be leaving and had worked the overnight shift. LPA advised ADM that facility shall be large enough to provide comfortable living accommodations and privacy to staff members who may reside in the facility.

At 10:15AM LPA toured the Wing A of the facility. LPA toured 13 resident rooms in Wing A. 13 out of 13 resident rooms had functioning lights, a bed, a dresser/table and storage space for personal belongings. 7 out of 7 resident bathrooms have paper towels, hand soap and functioning lights. LPA measured hot water temperature with a range from 105 to 112.2 degree F in resident bathrooms.

See LIC809C
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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 3
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: RACHELLE'S HOME III
FACILITY NUMBER: 445202879
VISIT DATE: 01/16/2025
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At 10:30AM, LPA toured resident room #1 and bathroom #1 (unoccupied), and observed the room was converted to storage space. LPA advised ADM to submit an updated facility sketch to include the converted bedroom #1 and bathroom #1 to storage space. LPA also observed 6 out of 7 resident bathrooms did not have slip-resistant mats on the floor.

At 10:45AM LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care.

The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM. Fire extinguishers were last serviced on 10/31/2024. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was on 11/24/24.

LPA reviewed 8 resident records. 8 out of 8 resident records were found to be complete. Resident records included emergency contact information, physician’s report, appraisal/needs and service plans, and personal rights. During resident record review, LPA observed that R3 and R8's medical assessment's ambulatory status is non-ambulatory. R3 and R8 occupy ambulatory rooms. LPA advised ADM to partner with the families of R3 and R8 to move residents to non-ambulatory rooms.

LPA reviewed 8 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). 8 out of 8 CSMDR’s were observed to be complete with all medication documented.

LPAs reviewed 7 staff records. 7 out of 7 staff records were found to be complete. Staff records included fingerprint background clearance, medical assessment with TB result, personnel record and staff training. LPA observed that 5 staff were not associated to the facility, but had obtained fingerprint background clearance. LPA advised ADM to associate staff to the facility by 1/17/2025.

Deficiencies were cited during today’s visit per California Code of Regulations Title 22. See LIC809-D. A Technical Violation was also issued. See LIC9102 for more information. An exit interview was conducted with ADM Myla Ilagan. A signed copy of this report and appeal rights were provided.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2025 04:13 PM - It Cannot Be Edited


Created By: Marcella Tarin On 01/16/2025 at 03:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: RACHELLE'S HOME III
FACILITY NUMBER: 445202879

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed 19 resident bathrooms did not have slip-resistant mats on the shower floors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Licensee states the facility will purchase slip-resistant mats and submit pictures of the mats to CCL by POC due date 1/17/2025. Licensee will conduct an in-service staff training regarding maintenance and operation, and submit documentation of training to CCL once completed.
Type A
Section Cited
CCR
87204(b)
Limitations -Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. During resident record review, LPA observed that R3 and R8's medical assessment's ambulatory status is non-ambulatory. R3 and R8 occupy ambulatory rooms (Resident Room #22 and #6) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Licensee will submit documentation of correspondence with R3 and R8's families to move R3 and R8 to non-ambulatory rooms by POC due date 1/17/2025. Licensee will also conduct an in-service staff training regarding ambulatory and non-ambulatory resident status and email documentation of training once completed to CCL.
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:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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