Routine inspection·October 31, 2024

Licensing Program Analyst (LPAs) Marcela Yanez and Mita Partoza. Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced Required 1 Year visit and met with Merclo Garcia Administrator, 3 staff-Bienvenido (Ben) and Ramiro Custodio (brothers), and Mary Wacheke and met with 5 residents (R1 to R5). During inspection LPAs observed a total of 7 bedrooms (1 of which is the upstairs office converted into a room which is not being utilized as a staff bedroom). Based on physical floor plan submitted to the department and during initial application, there are only 2 bedrooms on the first floor (#1 & #2) and 2 bedrooms on second floor (bedroom#3 and caregiver bedroom (no designated number) adjacent to the second floor stairway next to the bathroom. A review of the approved 3 STD 850 dated on 11/7/13 and 11/18/2013 are approved for 2 ambulatory and 4 non-ambulatory and on 12/4/2013, fire clearance change from 2 ambulatory, 3 non-ambulatory and 1 bedridden clearance in bedroom #2 on 1st floor. An overall analysis of the facility fire clearance, the facility is currently approved for 2 Ambulatory and 3 Non-Ambulatory and 1 bedridden clearance (as it states #1 and #2 on first floors are either ambulatory and/or non-ambulatory) and Bedroom #3 is ambulatory only and an office on the second floor. On 7/1/2024, Mr. Merclo Garcia was elected by the officers of the corporation the corporation as the new president/Administrator and Ramiro Custodio, a corporate member. Mr. Merclo stated that the former board members (Edralyn Lanzi and Rochelle Basco) stated that when they took over of the facility in 2013 from the previous licensee, the facility bedrooms already existed which is contrary to the submitted floor plan and fire clearances on file by Ms. Lanzi and Ms. Basco. Mr. Garcia will contact the former board members for additional information about the facility physical floor plan including the landlord and to contact the San Jose Fire Marshal to obtain history and building permits of the facility property building. The Department did not issue a citation on the discrepance of the fire clearance but advised to immediately contact SJFD and to submit a new fire clearance and updated new/updated floor plan request to CCLD before COB 11/1/2024. Page 1 of 3 Mr. Garcia will contact the former board members for additional information about the facility physical floor plan including the landlord and to contact the San Jose Fire Marshal to obtain history and building permits of the facility property building. The Department did not issue a citation on the discrepance of the fire clearance but advised to immediately contact SJFD and to submit a new fire clearance and updated new/updated floor plan request to CCLD before COB 11/1/2024. LPA observed 2 fire extinguishers 1 on the first and 1 second floor which were last inspected on 6/2023. LPA informed ADM to ensure that their fire extinguishers are inspected and current. The facility Fire and Earthquake log was last conducted on 07/15/2024. ADM stated that Fire and Earthquake or Disaster Drills are conducted every quarter. Smoke detector were tested and in good operating condition including carbon monoxide. There were also at least 22 tubes of triple antibiotics cream found in hallway closet across the living area unlocked. ADM stated the these antibiotics belonged to a former resident who was under hospice (name of resident unknown). LPA discussed with ADM regarding proper destruction of unused medications. During visit, LPAs toured the facility inside and out. LPAs observed food storage areas and locked cabinets for cleaning supplies including sharp objects. Cleaning solutions and other toxins were found accessible in the following areas bedroom, bathrooms, basement and outside underneath the ramp (all these are noted on LIC809-D). Food supplies for 7 day non-perishable and 2 days perishables were observed. During inspection of the facility food supplies for 7 days, there were only 20 can foods comprised of fruits and tomato soup. LPAs did not observed can foods variety in protein and vegetables. Also, LPAs reminded Administrator to have an Emergency food supplies in the facility such as can foods, water, emergency disaster kits. The facility was equipped with kitchen appliances such as but not limited to refrigerator, stove/oven and microwave. Inspections of these appliances noted to have stains, grease, crumbs and food residue wherein the Administrator was present during the inspections and photos were taken. Page 2 of 3 Surveillance cameras were observed during inspection visit in the following areas: carport, front/main door, living room, office (in the kitchen). ADM stated that cameras were installed or grandfather from the previous corporate members. ADM and S1 stated that cameras are recorded but no audio. LPAs advised ADM to submit a program plan for the use of surveillance cameras. Use of cameras does not specifically address on statutes, however, a waiver is needed when being used in private areas, and is allowed only in areas which does not infringe the personal rights of the residents. Audio is not allowed and is prohibited, and storing recording/records only those with legal authority to review it. ADM agreed and understood who will be submitting a program plan of the use of surveillance cameras. All bedrooms and common areas including staff bedroom were inspected. During inspection, the facility carpet had stains, and other unknown particles; the residents furniture were not dusted, and cobwebs were observed in the windows of the resident bedrooms and window screen had holes (only in bedroom #3 window). Moreover, there was a loose floor board in the dining area (LPM almost tripped during visit). Residents' prescribed and non-prescribed medication and the Centrally Stored Medication log residents were reviewed including their facility file record. All 5 residents did not have Appraisal, Needs and Services Plan including Consent forms wherein ADM was advised to obtain consent forms from residents' responsible parties. Staff record were also randomly reviewed, 3 staff (S1,S2,S3) files were reviewed wherein staff have a complete files including required training including first aid and/or CPR. During random audit of 3 residents' medications records, LPAs noted that medications for 3 residents were not documented on the centrally stored log. In addition, a nasal spray belongs to R1 was observed in the kitchen shelves, and also his/her PRN medications and 1 prescribed medication found in his/her unlocked closet and door which is accessible to any residents. Facility bathrooms were inspected equipped with non-skid mats, grab bars and handicap chairs and operational. Hygiene products and toiletries were observed and adequate. The facility hot water temperatures was also measured in the following areas: in the bathroom #1 sink measured with thermometer at 145.7 degrees F in b athroom #1, 130.1 degrees F in bathroom #2 and 140.1 in bathroom #3 and 141.1 in kitchen sink. During visit LPA suggested to remove stove knobs to prevent resident with neuro-cognitive disorder and mental illness to prevent resident from harm of fire and also discusses about facility hospice waiver stipulations such as notifying CCLD when accepting or discharging residents under hospice. and to review PIN 22-24 home health and hospice agency. LPA also suggested that door knobs should have single access mechanism for resident with neuro-cognitive disorder to access door in case of emergency or disaster. LPA informed ADM to post a Oxygen in use sign when a resident in hospice has one. LPAs also discussed about care and supervision for the residents who are on the first floor that there should be an on-call awake staff between (10pm and 6pm) per title 22 87415. all staff reside on second floor. there are 3 resident on the first floor 1 under hospice and 1 with mental illness. Deficiencies were cited as per California Code of Regulations Title 22, SEE LIC809-D. This report was reviewed with Merclo Garcia and Ben Custodio and a copy of this report and appeal rights discussed and provided. This document was signed by Bienvenido Custodio on behalf of Merclo Garcia who had to leave for work and deficiencies were discussed with Merclo Garcia. Page 3 of 3