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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600663
Report Date: 04/09/2025
Date Signed: 04/09/2025 11:57:28 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/06/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250206162914
FACILITY NAME:MONTEVERDE MANORFACILITY NUMBER:
415600663
ADMINISTRATOR:MARTIN, DINO MICHAELFACILITY TYPE:
740
ADDRESS:3420 FLEETWOOD DRIVETELEPHONE:
(650) 624-7624
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 5DATE:
04/09/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Dino MartinTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff neglected to provide medical attention to resident resulting in stage 4 injury.
INVESTIGATION FINDINGS:
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On 4/9/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint investigation findings. LPA met with the administrator and explained the purpose of today's visit.

Regarding to the allegation of- staff neglected to provide medical attention to resident resulting in stage 4 injury, there is no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that when resident #1( R1) was admitted to the facility with a stage 2 pressure ulcer and when R1 was transferred to the hospital due to a change in health condition, the pressure ulcer got worse to a stage 4. The reporting party stated that R1 feels neglected by the facility and did not receive the proper care.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20250206162914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MONTEVERDE MANOR
FACILITY NUMBER: 415600663
VISIT DATE: 04/09/2025
NARRATIVE
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As part of the investigation, LPA interviewed R1, the administrator, staff member and review documentation,

LPA interviewed R1 who stated that facility staff was providing good care and R1 was comfortable at the facility.

The administrator denied the allegation and stated that R1 was admitted with a pressure ulcer and home health nurse was providing treatment to the wound. However, R1 was not compliant with being turned and repositioned resulting wound got worse. The administrator stated that this observation was noted and documented by the home health nurse and facility staff.

LPA interviewed staff #1(S1) who stated that they turned and repositioned R1 every 2 hours but sometimes R1 did not want to comply, but they continued to encourage. S1 stated that R1’s wound was being treated by the home health and hospice nurses.

Based on documentation provided by the facility, it revealed that R1 was refusing to be turned by the facility staff and refused pressure injury prevention measures that were recommended by the home health nurse.

After the investigation, this allegation is deemed to be unfounded as R1 stated that he/she was comfortable and facility staff was providing good care. In addition, facility documentation indicated that R1 was refusing pressure ulcer prevention measures and safety precautions.

The Department has investigated the complaint allegations of possible physical plant violations. It was determined the allegations are unfounded, meaning the allegations are false, could not have happened and/or is without a reasonable basis and therefore dismissed.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2