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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294274
Report Date: 11/12/2020
Date Signed: 11/23/2020 10:24:22 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MAPLE HOUSE II, THEFACILITY NUMBER:
445294274
ADMINISTRATOR:CHEN, HONG-GENFACILITY TYPE:
740
ADDRESS:2000 BROMMER STREETTELEPHONE:
(831) 476-6366
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:40CENSUS: 18DATE:
11/12/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Damien Anderson, Temporary ManagerTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Gladys Kuizon and Ryker Heberle conducted a Case Management tele-visit today in collaboration with CA Department of Public Health (CDPH), Santa Cruz County Long Term Ombudsman (LTCO), and Santa Cruz County Public Health Department (LHD).

LPAs met with Temporary Manager (TM) Damien Anderson, Administrator Sara Chen, CDPH-Health Facilities Evaluator Nurse (HFEN) Janet Hayes, LTCO Deanna Trinidad, LHD Katie Williams, and CDPH Healthcare-Associated Infections (HAI) Program surveyor Kristy Trausch, and Community Care Licensing Division (CCLD) Program Clinical Consultant (PCC) Roxanne Fangon.

HAI was on-site and LPAs joined the facility tour at 11:24 AM. The tour started from the facility's main lobby area and proceeded through the hallways leading to the residents' rooms. COVID-19 postings were observed. Bedrooms occupied by COVID-19 positive residents were marked and a clear, plastic protective barrier was placed on the doorway. Door was observed open on one COVID-19 positive resident's room. Covered trash bins were observed outside isolation rooms. Facility staff were observed wearing Personal Protective Equipment (PPE) including face mask, face shield, hair cover, and green reusable gowns. On 11/03/2020, green surgical gowns were observed by LPA and HFEN hung on a rack with N95 masks and face shield. Administrator stated gowns were not washed since Saturday (October 31, 2020). HFEN advised Administrator Chen about proper PPE use and advised against using reusable gowns. CCLD arranged to have disposable gowns sent to the facility immediately. Administrator confirmed that disposable gowns were received by the facility. During visit today, HAI also recommended against the use of reusable gowns which staff was observed still using.

At 12:01 PM, the dining room was toured. No residents were present. Tables were observed at least 6 feet from each other. A dedicated break room for COVID-19 positive staff was observed.

Continued, see LIC 809-C, page 2 of 2.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MAPLE HOUSE II, THE
FACILITY NUMBER: 445294274
VISIT DATE: 11/12/2020
NARRATIVE
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At 12:11 PM, the facility's laundry room was inspected. Laundry procedures were reviewed by HAI. The facility tour ended at 12:17 PM.

Written report from HAI with recommendations provided today is pending at this time and will be discussed with facility once received.

A deficiency is being cited. See LIC 809-D. Exit interview conducted with Temporary Manager Damien Anderson and Brooke Lowther.

A copy of this report was provided to Temporary Manager via email for signature. Appeal rights provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MAPLE HOUSE II, THE
FACILITY NUMBER: 445294274
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2020
Section Cited

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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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This requirement was not met as evidenced by: During facility tour today, staff was observed using reusable gowns against HFEN's advise on 11/03/20.
This poses an immediate health and safety risk to residents in care.
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3