430702352-8-29-2023-26-AS-KHOS-CXASY9-20231105131709

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430702352
Report Date: 08/29/2023
Date Signed: 08/29/2023 05:02:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
08/25/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230825125338

FACILITY NAME:	VALLEY PINES		FACILITY NUMBER:	430702352
ADMINISTRATOR:	HEINAN, JAMES		FACILITY TYPE:	740
ADDRESS:	545 EAST MAIN AVENUE		TELEPHONE:	(408) 779-2855
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	49	CENSUS: 22	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Carolyn Heinan		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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A resident was found on the street wandering without supervision
Staff did not administer resident’s medication per physician’s order

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Licensees James and Carolyn Heinan.

On 08/25/2023, the Department received a complaint alleging the above allegations. On 08/29/2023, the initial complaint investigation was conducted.

The following documents were obtained for this investigation to include the staff schedule for August 2023, resident roster, resident (R1)’s admission agreement, physician’s report, personal rights form, consent form, preplacement appraisal information, medication list, centrally stored medication record, and doctor communication.

SEE LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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 4

Control Number 26-AS-20230825125338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VALLEY PINES	FACILITY NUMBER: 430702352
	VISIT DATE: 08/29/2023

NARRATIVE

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On 08/29/2023, 2 staff were interviewed. Based on interview, on 08/24/2023 around 04:00am, resident (R1) exited the facility without notice. R1 was found at a traffic light within steps of the facility continuously pressing the pedestrian button. A concerned citizen contacted the police and the licensee was notified of the incident. S1 states to have gone to tend to R1 until police arrived. The police officers escorted R1 back to his/her bedroom.

Based on record review, R1 is able to leave the facility unassisted. S1 states to have worked the NOC shift and did not hear R1 leaving the facility.

Based on interview, R1 is able to store his/her own medications per R1’s physician’s report. Due to R1’s observed behaviors, the facility had concerns regarding R1’s health and safety of storing his/her medications. R1’s responsible party was contacted in which they agreed to have the facility store/administer R1’s medications for R1’s health and safety. S1 states, R1’s medications were being administered daily, however, R1 refused medications for one day.

Based on record review, R1 is able to store his/her own medications. Records show the facility’s attempt to contact R1’s physician for an updated physician’s report and physician’s orders.

On 08/29/2023, 3 witnesses were interviewed. Based on interviews, the facility was provided consent by R1’s responsible party to store/administer R1’s medications for R1’s health and safety. It was believed that R1 had refused to take his/her medications from the staff. The facility was in frequent communication with R1’s case manager regarding R1’s medications, however, the facility was not receiving timely response by R1’s doctor.

On 08/29/2023, 3 residents were interviewed. 3 out of 3 residents state they are provided their medications daily by staff.

The Department has investigated the above allegations. Based on interview, record review and observation, the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegations may have happened and/or is valid there is a not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensees and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
08/25/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230825125338

FACILITY NAME:	VALLEY PINES		FACILITY NUMBER:	430702352
ADMINISTRATOR:	HEINAN, JAMES		FACILITY TYPE:	740
ADDRESS:	545 EAST MAIN AVENUE		TELEPHONE:	(408) 779-2855
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	49	CENSUS: 22	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Carolyn Heinan		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Staff forced resident in care to stay in bed
Staff confiscated resident’s cellular phone

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20230825125338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VALLEY PINES	FACILITY NUMBER: 430702352
	VISIT DATE: 08/29/2023

NARRATIVE

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On 08/29/2023, 2 staff were interviewed. Based on interview, on 08/24/2023 around 04:00am, resident (R1) exited the facility without notice. R1 was found at a traffic light within steps of the facility continuously pressing the pedestrian button. A concerned citizen contacted the police and the licensee was notified of the incident. S1 states to have gone to tend to R1 until police arrived. The police officers escorted R1 back to his/her bedroom. After the incident S1 sat in the hallway of R1’s bedroom to provide R1 supervision and ensure R1’s safety. 2 out of 2 staff denied forcing the resident to stay in bed.

2 out of 2 staff denied confiscating R1’s cellular phone.

On 08/29/2023, 3 residents were interviewed. 3 out of 3 residents were never forced to stay in bed by the staff. 3 out of 3 residents have never gotten their cellular phone confiscated by the staff.

On 08/29/2023, 3 witnessed were interviewed. 3 out of 3 witnesses denied knowledge of R1 being forced to stay in bed. 3 out of 3 witnesses denied knowledge of R1’s cellular phone being confiscated by staff. W3 states the presence of R1’s cellphone in R1’s bedroom at the facility. 3 out of 3 witnesses state they were able to get a hold and contact R1.

Based on record review, R1 signed and acknowledged his/her personal rights.

The Department has investigated the above allegations. Based on interview, record review, and observation the above allegation is unfounded, meaning the allegation is false could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensees and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

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