430707358-10-6-2023-26-AS-CDOS-CWCW4Q-20231006165754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430707358
Report Date: 10/06/2023
Date Signed: 10/06/2023 04:58:02 PM

Document Has Been Signed on 10/06/2023 04:58 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:	LA CASA DEL PUENTE		FACILITY NUMBER:	430707358
ADMINISTRATOR:	JENNIFER NGUYEN		FACILITY TYPE:	772
ADDRESS:	17415 & 17425 DEPOT STREET		TELEPHONE:	(408) 778-0555
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY: 12		CENSUS: 12	DATE:	10/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Matthew Miao		TIME COMPLETED:	05:05 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 inspection. LPA met with Program Director, Matthew Miao. During visit LPA toured the facility with staff to include the entrance, common area, dining room, kitchens, resident bedrooms, bathrooms, office space, backyard, storage unit in the backyard, and exterior. All fire exit routes were free and clear of obstruction. Facility temperature maintained between 73 - 74 degrees Fahrenheit. Fire extinguishers last serviced on 05/14/2023. Carbon monoxide detectors present in the hallway of each sleeping area. At least two direct care staff and a case manager were present. Facility was not able to produce their infection control plan during visit. Facility was advised. Personal Protective Equipment (PPE) supplies were observed to include gowns, gloves, masks, hand sanitizers, and disinfectants. Client bedrooms contains beds, linens, closet space, lighting, and a dresser for each client. Bathrooms are equipped with toilet, showers, paper products, hygiene supplies, and hand washing signs. Hot water temperature maintained at 108-110 degrees Fahrenheit. Smoke detector observed in the hallway of each sleeping area in the facility. Kitchen is supplied with cups, plates, bowls, and utensils. Facility has at least 2 days worth of perishable foods and 7 days worth of non-perishable foods. Refrigerator #1 and #2's temperature maintained at 35 degrees Fahrenheit. Freezer #1 and #3 temperature maintained below 0 degrees Fahrenheit. Freezer #2's temperature maintained at 12 degrees Fahrenheit. Facility was advised to ensure each freezer temperature is maintained at 0 degrees Fahrenheit. PAGE 1 OF 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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 5

Document Has Been Signed on 10/06/2023 04:58 PM - It Cannot Be Edited

Created By: Christine Dolores On 10/06/2023 at 04:00 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: LA CASA DEL PUENTE	FACILITY NUMBER: 430707358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1522(c)(1)

General Provisions

(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, resience, or intitial presence in 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 licensee did not ensure staff (S5) was fingerprint cleared from the Department prior to starting work which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2023
	Plan of Correction
1 2 3 4	Staff (S5) was immediately released from work. Licensee will ensure staff obtains a fingerprint clearance from the Department prior to returning to work. Licensee will submit their plan in writting going forward to ensure all new staff are fingerprint cleared.

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

LICENSING EVALUATOR NAME:

Christine Dolores

LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 10/06/2023 04:58 PM - It Cannot Be Edited

Created By: Christine Dolores On 10/06/2023 at 04:00 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: LA CASA DEL PUENTE	FACILITY NUMBER: 430707358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81095.5(c)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 81022. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee was not able to produce the faicloty's infection control plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee will develop an infection control plan and will submit the infection control plan to LPA Dolores via email by POC due date.

Type B

Section Cited

CCR

81069(a)

Client Medical Assessments

(a) Prior to admitting a client into care or within 72 hours of admission, the licensee shall obtain and keep on file documentation of the client's medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not ensure resident (R5) medical assessment was on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee will schedule an appointment with R5's physician to get an updated medical assessment. Licensee will ensure all future clients will have a completed medical assessment done prior to admission. Licensee will submit to LPA Dolores a written letter to ensure R5 and all new clients will have a medical assessment on file 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

LICENSING EVALUATOR NAME:

Christine Dolores

LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: LA CASA DEL PUENTE	FACILITY NUMBER: 430707358
	VISIT DATE: 10/06/2023

NARRATIVE

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Facility was advised to inspect the food in Freezer #2 and relocate the food between the other freezers. Sharp objects, cleaning solutions, and disinfectants observed locked and secured. Weekly menu posted in a public area for review.

The facility has a storage area that contains all non-perishable foods. LPA observed items inside the pantry that exceeded the "best by" date on the label. Based on interview, the facility follows the Second Harvest of Silicon Valley food safety instructions regarding freshness and quality of perishables and non-perishable foods. LPA observed the poster located in the pantry. Facility was advised to follow the Department of U.S. Agriculture guidelines regarding food safety. LPA advised that the facility's foods should be of good quality. The non-perishable cans were not open and did not contain obvious rust, dents, or damages.

Facility has an updated emergency disaster plan. Emergency evacuation map posted throughout the facility. The facility's first aid kit observed with bandages, tweezers, scissors, gauze, and a manual. Some supplies such as, emergency water, food, and batteries observed expired inside the first aid kit backpack. Facility was advised. Emergency supplies observed to include flash lights and batteries. Staff and clients were provided quarterly emergency disaster drills.

LPA reviewed 5 client (C1 - C5) files to contain an admission agreement, medical assessment, TB result, appraisal/needs and services plan, emergency forms, safeguard of personal property and valuables, and personal rights. Resident (R5)'s file did not contain a physician's report and TB result. Facility was advised. LPA reviewed 5 clients centrally stored medication record and P&I money. 3 clients were interviewed.

LPA reviewed 5 staff files with the facility's human resource (HR) personnel virtually using the PD’s laptop. During the virtual meeting, HR showed R1 - R5's health screening, TB results, job applications, and fingerprint clearance. It was found S5’s background clearance application is closed, therefore, S5 is not fingerprint cleared. S5 was immediately released from work. PAGE 2 OF 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: LA CASA DEL PUENTE	FACILITY NUMBER: 430707358
	VISIT DATE: 10/06/2023

NARRATIVE

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S4 - S5's file did not contain a health screening form. 4 out of 5 staff members obtains an updated first aid certification. LPA reviewed staff training records. LPA interviewed 2 staff members.

LIC500 Personnel Report obtained during visit.

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 staff (S5) working at the facility without fingerprint clearance. Please see LIC 421BG.

Plans of corrections were developed with the PD. This report was reviewed with Program Director, Matthew Miao and a copy of the report and appeal rights were provided.

PAGE 3 OF 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5