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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430707832
Report Date: 10/26/2021
Date Signed: 10/26/2021 03:44:06 PM

Unsubstantiated


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
08/17/2020 and conducted by Evaluator Yatfai Ng
COMPLAINT CONTROL NUMBER: 26-AS-20200817090611
FACILITY NAME:SUB-ACUTE RESIDENTIAL TREATMENT (SART)FACILITY NUMBER:
430707832
ADMINISTRATOR:MICHELLE MECIRFACILITY TYPE:
772
ADDRESS:230 N. MORRISON AVE.TELEPHONE:
(408) 938-8516
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:16CENSUS: 12DATE:
10/26/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Fernando PazTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility retaining resident that require a higher level of care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent investigation visit to deliver the findings. LPA met with the Program Manager (PM) Fernando Paz.

An initial unannounced tele-investigation was conducted by LPA on 08/20/2020. LPA interviewed 1 staff and obtained 2 physician’s reports and progress notes. On 08/20/2021, LPA reinterviewed the same staff and obtained 2 discharge notes.

Between 08/20/2020 and 08/20/2021, 1 staff was interviewed. 1 out of 1 staff denied facility retaining resident that require a higher level of care. A prospective resident would be evaluated and had to be suitable for the facility before being admitted. The alleged victim (R1) was interviewed and at the moment found to be suitable to stay in the facility with continuous monitoring.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
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)
Page: 1 of 2
Control Number 26-AS-20200817090611
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: SUB-ACUTE RESIDENTIAL TREATMENT (SART)
FACILITY NUMBER: 430707832
VISIT DATE: 10/26/2021
NARRATIVE
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R1’s physician’s report stated that R1 wore diaper and sometimes had difficulty swallowing. However, R1 did not require skilled nursing care. The medical service progress note noted the physician ordered the staff to monitor R1’s ability to take medication by mouth and ordered the staff to monitor R1’s continence in toileting needs. The physician did not deny admission of R1.

An updated residential progress notes of R1 showed R1 was discharged several days later after admission. It was noted R1 was not able to maintain his/her hygiene.

Based on record review and interviews, it was noted R1 was interviewed by a physician. R1 was admitted to the facility and being continuously monitored. The staff later observed R1 became an unfit in the facility. Thus, a discharge note was issued to R1.

Based on interviews and record review, the department has determined that the allegation was UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

This report was reviewed with PM. A copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
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)
Page: 2 of 2