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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430702352
Report Date: 01/10/2025
Date Signed: 01/10/2025 04:31:28 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
09/10/2024 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20240910121029
FACILITY NAME:VALLEY PINESFACILITY NUMBER:
430702352
ADMINISTRATOR:HEINAN, JAMESFACILITY TYPE:
740
ADDRESS:545 EAST MAIN AVENUETELEPHONE:
(408) 779-2855
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:49CENSUS: 15DATE:
01/10/2025
UNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Carolyn and James HeinanTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Facility staff did not follow the resident's care plan
Facility staff mentally abuses a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived unannounced to deliver the finding regarding the above allegation. LPA met with Licensee / Administrator Carolyn Heinan and James Heinan.

On 09/10/2024, the Department received the complaint. On 09/16/2024, the initial complaint investigation was conducted. The following documents were obtained to include resident (R1)’s admission agreement, physician’s report, appraisal/needs and services plan, preplacement appraisal, identification and emergency contact information, centrally stored medication record, incident report, and LIC500.

It was alleged that the facility staff did not follow the resident’s care plan as the licensee stated to R1’s private caregiver that R1 needed a 2-person assist for transfers, when during the assessment a 2-person assist transfer was not indicated. Page 1 of 4.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
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 7
Control Number 26-AS-20240910121029
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: 01/10/2025
NARRATIVE
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Based on interview and record review, R1’s care plan was not updated prior to LPAs visit on 09/16/2024, to indicate that R1 required a 2-person assist. It was stated that the Licensee was not part of the assessment with R1’s family member and home health agency on 09/06/2024 and was unsure of their discussion / care plan developed.

On 09/09/2024, R1’s private caregiver through a home health agency, started services at the facility to help with R1’s care needs. Based on interview with the private caregiver (W1), it was stated that W1 was trying to put R1 to bed but was unable to transfer R1 from wheelchair to bed by him/herself and needed a second person for assistance. W1 described themselves as a small and petite individual who did not receive any training from the home health agency nor have any caregiving experience prior to providing care to R1. W1 states that he/she called the Licensee for assistance, but the Licensee was unable to assist with the transfer due to back pain. W1 stated that the Licensee advised W1 to call 911 for a “lift-and-assist” as the facility staff were unable to provide secondary assistance to transfer R1 from the wheelchair to bed. W1 stated to have called the lift-and-assist who shortly arrived at the facility.

On 09/16/2024, 4 staff members were interviewed. The Licensee stated that there was a caregiver who left the facility on 08/31/2024, who knew how to care for R1. This caregiver provided training to a facility staff before departure, however, this facility staff stated that due to back pain and safety reasons, the staff was unable to transfer R1 by him/herself. Based on staff interview, 4 out of 4 staff members stated that due to safety reasons, R1 requires a 2-person assist to get R1 in and out of bed. It was stated that R1 is in a lot of pain and is unable to bear weight during transfers making it difficult for one person to assist R1.

The licensee stated that upon departure of the staff who was providing care to R1, they had spoken with R1’s family member regarding the inability to assist with transferring R1 due to the lack of capable staff, back pain and the licensees age. The licensee stated to have advised family to find R1 a new placement who can better meet R1’s needs.

Page 2 of 4.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20240910121029
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: 01/10/2025
NARRATIVE
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It was alleged that the licensee mentally abuses R1 by putting it into R1’s mind that R1 has dementia and would deny R1’s reality of the actual events. It was alleged that on 09/09/2024 the fire fighters, paramedics and police were at the facility and when R1 asked the licensee if the police were there, it was alleged that the licensee would deny the reality and put it into R1’s mind that R1 has dementia.

Based on record review, R1 is diagnosed with mild cognitive impairment. Based on R1’s service plan, its indicated that R1 has mild forgetfulness.

4 witnesses were interviewed. Based on interview, 3 out of 4 witnesses denied the observation of the licensee stating R1 has dementia. 3 out of 4 witnesses denied the observation of the licensee confusing R1’s reality.

1 out of 4 witnesses stated that the licensee has told R1 that he/she has dementia and denies R1’s reality that is causing R1 to become confused. W4 states that R1 questioned if the firemen and paramedics were real, in which W4 confirmed the reality. W4 stated that the licensee has commented to R1’s face stating that R1 does not know what he/she is talking about, is too much trouble, and threatened to put R1 into the streets.

On 09/16/2024, 7 staff members were interviewed to include the licensee. The licensee denied the allegation and denied stating that R1 has dementia to his/her face. Licensee stated that R1 has forgetfulness. The Licensee denied intentionally yelling or hurting R1’s feelings and denied threatening to put R1 into the streets. The licensee states that R1 and the licensee jokes in German, which the tone can be heard as loud, but the conversations were always friendly. The Licensee stated that he/she does not remember R1 asking about the incident that occurred the night of 09/09/2024. The remainder of the staff interviewed denied the observation of the licensee mentally abusing R1 and other residents in care.

Page 3 of 4.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20240910121029
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: 01/10/2025
NARRATIVE
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On 09/16/2024, R1 was interviewed. Based on interview, R1 stated that the staff treat him/her nicely. R1 stated that the licensee treats him/her nicely and had no complaints about the licensee. R1 states that he/she likes to speak German with the licensee and states to have playful conversations with the licensee. R1 denied the licensee saying mean things or confusing R1. When LPA asked R1 about the night the paramedics arrived to assist R1 to bed, R1 stated that nothing happened that day and did not elaborate further about the incident.

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 allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Licensee / Administrator Carolyn Heinan and and James Heinan and a copy of the report was provided.

Page 4 of 4.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
09/10/2024 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20240910121029

FACILITY NAME:VALLEY PINESFACILITY NUMBER:
430702352
ADMINISTRATOR:HEINAN, JAMESFACILITY TYPE:
740
ADDRESS:545 EAST MAIN AVENUETELEPHONE:
(408) 779-2855
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:49CENSUS: DATE:
01/10/2025
UNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Carolyn and James HeinanTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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9
Facility staff neglected resident by impeding in a transfer resulting in the resident being left in a wheelchair for many hours during the night
Facility does not have an awake night staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived unannounced to deliver the finding regarding the above allegation. LPA met with Licensee / Administrator Carolyn Heinan and James Heinan.

On 09/10/2024, the Department received the complaint. On 09/16/2024, the initial complaint investigation was conducted. The following documents were obtained to include resident (R1)’s admission agreement, physician’s report, appraisal/needs and services plan, preplacement appraisal, identification and emergency contact information, centrally stored medication record, incident report, and LIC500.

It was alleged that on 09/09/2024, the licensee neglected resident (R1) by impeding in a transfer by yelling at R1’s private caregiver stating that R1 is a 2-person assist, resulting in R1 sitting in his/her wheelchair for hours during the night. Page 1 of 3.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20240910121029
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: 01/10/2025
NARRATIVE
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On 09/09/2024, R1’s private caregiver through a home health agency, started services at the facility to help with R1’s care needs. Based on interview with the private caregiver (W1), it was stated that W1 did not receive any training from the home health agency nor have any caregiving experience prior to providing care to R1. W1 states that he/she was unable to transfer R1 from the wheelchair to bed alone and asked the licensee for assistance, which the licensee was unable to provide due to back pain. W1 was instructed by the licensee to call for a “lift-and-assist”. W1 stated that the fire fighters arrived and was unable to move R1 to bed because R1 would scream anytime they tried to lift him/her. W1 stated that because R1 refused to be moved, the fire fighters left and stated that they could not force R1.

Based on interview with the licensees, it was stated that the fire department showed up at the facility around 7:30pm but because R1 refused to be moved from the wheelchair to bed, the fire department left. The licensee stated to have checked in on R1 around 10pm, however, R1 still refused to go to bed. R1’s family member was informed of the situation. Around 12am, the licensee called 911 and paramedics were able to assist R1 to bed. The licensee states the reason for the delay was because they did not want to upset R1’s family members and they were waiting for a response from the family members on what to do, as R1 was refusing to be lifted to bed. The licensees denied impeding in the transfer.

Based on interview with W1, W1 denied the licensees impeding in the transfer between the fire fighters. W1 stated that all parties were trying to get R1 to bed, but R1 was refusing. W1 denied the licensee impeding in R1’s transfer and stated that R1 needed secondary assistance to move R1 from wheelchair to bed.

It was alleged that the facility does not have an awake night staff or security checking the residents throughout the night.

Page 2 of 3.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20240910121029
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: 01/10/2025
NARRATIVE
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Based on interview with the licensees, it was stated the staff are consistent and know their hours of work, in which they do not write a staffing schedule. It was stated that one of the licensees covers the night shift and the licensee’s do not clock in and out of work as they are the owners of the business.

On 09/16/2024, 7 staff members were interviewed. Based on interview, 7 out of 7 staff stated that the facility has an awake night staff and live-in staff available on-call. It was stated that one of the licensee covers the night shift.

Based on record review of the facility's staffing record that was submitted to the Department, the facility has a night shift staff scheduled to cover from 9:00pm - 7:00am.

The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are 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 Licensee / Administrator Carolyn Heinan and and James Heinan and a copy of the report was provided.

Page 3 of 3.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7