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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202199
Report Date: 02/10/2023
Date Signed: 02/10/2023 05:36:33 PM

Document Has Been Signed on 02/10/2023 05:36 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:SCHLOSSER HOMEFACILITY NUMBER:
435202199
ADMINISTRATOR:APRIL MAIMONFACILITY TYPE:
735
ADDRESS:3314 LYNN OAKS DR.TELEPHONE:
(408) 982-3103
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 6CENSUS: 3DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Christian PeytonTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator (ADM), Christian Peyton.

During visit, LPA toured the facility with ADM to include the kitchen, laundry room, living room, bathrooms, bedrooms, and exterior. The sliding door exit leading to the backyard was blocked by a outdoor couch. ADM removed the couch to clear the exit. LPA observed a set of knives on the kitchen counter, drawer of knives, and knife on the drying rack that was left accessible to residents in care. Staff immediately secured the sharp objects. LPA observed a resident's medication on the kitchen counter and over the counter medication in the refrigerator. Staff secured medications. The facility is not observed clean by having a lot of dust, debris, and pet hair build-up on the floors of the facility, kitchen appliances were not wiped down, showers had collection of build-up dirt, and piles of dirty dishes next to the kitchen sink from the night before.

Facility has a central entry point for visitor sign-in. LPA was not screened for COVID-19 symptoms or did not have temperature taken upon entry. ADM was asked to remove the no visitor sign posted at the entry. Hand sanitizer and face masks made available at the entry. Facility does not have an adequate supply of all Personal Protective Equipment (PPE) supplies, to include gowns. Bathrooms supplies with hygiene products, hand washing sign, and paper supplies. Facility staff has not been provided training on infection control. Facility staff are not N95 fit tested. Resident's symptoms and temperature are being documented daily but the records are given to the resident's day programs and not retained at the facility. Facility does not have a lidded trash bin. COVID-19 posters observed to include droplet precaution and symptoms of COVID-19.

LPA requested the following documents to include LIC500, LIC610D, Infection Control Plan, and change of Administrator Documents by Monday 02/13/23.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809Ds. Advisory notes provided. This report was reviewed with the Administrator, Christina Peyton and a copy of the report and appeal rights were provided.
Sarah Yip
Christine Dolores
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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 12
Document Has Been Signed on 02/10/2023 05:36 PM - It Cannot Be Edited


Created By: Christine Dolores On 02/10/2023 at 04:52 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: SCHLOSSER HOME
FACILITY NUMBER: 435202199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not securing cleaning solutions such as laundry detergents and bleach which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2023
Plan of Correction
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Licensee will ensure to secure cleaning solutions and disinfectants at all times. Licensee will send their plan to ensure these items will be stored inaccesible to clients. Licensee will review section 80087 and send a statement of understanding to LPA by POC due date.
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by leaving knives accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2023
Plan of Correction
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Licensee immediately secured the knives. Licensee will fix the drawer for sharps to ensure they are kept locked and inaccesible at all times. Licensee will submit their plan in writing to ensure knives and sharp objects will be kept inaccesible at all times. Licensee will submit their POC to LPA 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: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023


LIC809 (FAS) - (06/04)
Page: 2 of 12
Document Has Been Signed on 02/10/2023 05:36 PM - It Cannot Be Edited


Created By: Christine Dolores On 02/10/2023 at 04:52 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: SCHLOSSER HOME
FACILITY NUMBER: 435202199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by having a residen's medication accessible on the kitchen counter and over the counter medication in the refridgerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2023
Plan of Correction
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Licensee immediately secured the medications. Licensee will review section 80075 and send a statement of understanding to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023


LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 02/10/2023 05:36 PM - It Cannot Be Edited


Created By: Christine Dolores On 02/10/2023 at 04:52 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: SCHLOSSER HOME
FACILITY NUMBER: 435202199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA observed the facility was not clean by having a lot of dust, debris, and pet hair build-up on the floors, kitchen appliances were not wiped down, showers had collection of build-up dirt, and piles of dirty dishes next to the kitchen sink from the night beforewhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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Licensee will ensure to clean the facility. Licensee will send a plan to ensure the facility will be kept clean, safe, and sanitary to LPA by POC due date.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the sliding door exit leading to the backyard was blocked by a outdoor couch which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Citation was immediately corrected.
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: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023


LIC809 (FAS) - (06/04)
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