430702352-10-27-2021-26-AS-KHOS-C88HV8-20211028063130

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430702352
Report Date: 10/26/2021
Date Signed: 10/27/2021 02:45:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2020 and conducted by Evaluator Anna Bui

COMPLAINT CONTROL NUMBER: 26-AS-20201012142621

FACILITY NAME:	VALLEY PINES		FACILITY NUMBER:	430702352
ADMINISTRATOR:	HEINAN, CAROLYN		FACILITY TYPE:	740
ADDRESS:	545 EAST MAIN AVENUE		TELEPHONE:	(408) 779-2855
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	49	CENSUS: 19	DATE:	10/26/2021
		UNANNOUNCED	TIME BEGAN:	01:22 PM
MET WITH:	James Heinan		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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The facility did not provide copies of a resident's records to the responsible party.
The facility did not maintain resident's records for a minimum of 3 years.

INVESTIGATION FINDINGS:

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On 10/26/2021 at 1:22 pm, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced complaint investigation visit to deliver the finding to the above allegations. LPA met with Administrator James Heinan (ADM).

On 10/27/2020, the Department conducted an initial 10-day investigation for the above allegations.

Between 10/27/2020 and 10/26/2021, the ADM was interviewed. ADM stated R1 moved to the facility on 03/19/2018. ADM stated all R1’s records were provided to R1’s responsible party. ADM stated after a resident is discharged from the facility, they maintain the documents for a minimum of 3 years. The Department requested R1’s documents that were provided to the responsible party.

-Continued, see LIC 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20201012142621

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VALLEY PINES	FACILITY NUMBER: 430702352
	VISIT DATE: 10/26/2021

NARRATIVE

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Between 10/29/2020 and 07/08/2021, the Department interviewed the Licensee. During the interview, Licensee stated R1’s records were released to R1’s Power of Attorney (POA) on 10/10/2021. Licensee stated hospital discharge papers, medical records, and medication list were also included in the documents that were provided to the POA.

On 11/06/2021, the Department interviewed R1’s Power of Attorney (POA). R1’s POA stated they received R1’s records from the facility on 10/10/2021.

Facility records were also reviewed. R1’s record had paperwork on file since R1 moved in, including admission agreements, physician’s reports, LIC 625 (Appraisal/Needs and Services Plan), Doctor’s Visit Summary Report, and Medication Records.

The Department has completed the investigation of the above allegations. Based on interviews and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies were cited during today’s visit.

This report was discussed with Administrator James Heinan and a copy was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

LIC9099 (FAS) - (06/04)

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