430707868-12-2-2022-26-AS-KHOS-CMLNSQ-20221230094330

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430707868
Report Date: 12/02/2022
Date Signed: 12/02/2022 04:51:07 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
12/14/2021 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20211214154543

FACILITY NAME:	FLORENCE RESIDENTIAL CARE HOME #2		FACILITY NUMBER:	430707868
ADMINISTRATOR:	PERLA DIMALANTA ZEIJNALI		FACILITY TYPE:	735
ADDRESS:	135 NORTH 8TH STREET		TELEPHONE:	(408) 293-0362
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	10	CENSUS: 10	DATE:	12/02/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Mary-Jane Ikner		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident is malnourished.
Resident was illegally evicted.
Resident has lice.
Facility is dirty.

INVESTIGATION FINDINGS:

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On 12/14/2021, the Department received a complaint with the above allegations. On 12/16/2021, the Department conducted an initial complaint investigation visit and met with Mary-Jane Ikner.

The review of R1’s medical records noted several hospital visits in December and couple visits in November 2021. On 11/9/21, R1 was treated for hypoglycemia, and generalized weakness/malnourishment; however, it was noted generalized weakness/malnourishment “may be falsely elevated due to large doses of Vitamin B7.” On 11/30/21, R1 was taken to the hospital for gait problem. The medical records noted R1’s weight was 110lbs and no mention of malnourishment. In December 2021, R1 was taken to the hospital three times for weakness and pain. Again, there was no mention of R1 being malnourished on each visit report. R1’s weight in December ranged from 100-110 lbs. R1 was interviewed and stated to have eaten breakfast, lunch, and dinner at the facility and purchased food within the community.

See LIC9099-C for more information. Page 1 of 4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

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-20211214154543

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: FLORENCE RESIDENTIAL CARE HOME #2	FACILITY NUMBER: 430707868
	VISIT DATE: 12/02/2022

NARRATIVE

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On 06/17/2022, LPA Marrufo conducted a visit at the facility and observed meal service at the facility. LPA Marrufo observed 5 residents being served meals. LPA Marrufo observed the facility food supply and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days.

During today’s visit on 12/02/2022, LPA Marrufo observed the kitchen cabinets, kitchen refrigerator, and freezer located in the dinning area and found them to have a perishable food supply of 2 days and a non-perishable food supply of at least 10 days.

LPA Marrufo interviewed 5 residents and had attempted interviews with two residents who either refused to be interviewed or were asleep during visit. 5 out of 5 interviewed residents stated the staff serve 3 meals a day. 5 out of 5 residents stated they can ask for seconds during meals. 4 out of 5 residents stated the served meals are nutritious.

Administrator (ADM) Perla Zeijnali stated during interview that residents are served three meals per day.

R1’s Physician’s Report states R1 is on a special diet of low carbohydrates due to diabetes. ADM stated staff encourage all residents with diabetes to not eat rice or carbohydrates of any other sort, but sometimes the residents will request them anyway.

Two family members were interviewed. 1 out of 2 stated R1 was taken to the hospital on 12/9/21 and facility wanted to evict R1.

Administrator (ADM) was interviewed and stated that R1 was not issued an eviction notice and was not evicted from the facility. ADM stated R1 needed to be placed in a higher level of care and ADM and R1’s family agreed to move R1 to another facility. ADM stated R1 was not able to walk without assistance and needed a walker. ADM stated the facility is licensed for ambulatory residents only. LPA Marrufo reviewed the facility fire clearance and confirmed the facility has a fire clearance allowing only ambulatory residents.

Page 2 of 4.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20211214154543

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: FLORENCE RESIDENTIAL CARE HOME #2	FACILITY NUMBER: 430707868
	VISIT DATE: 12/02/2022

NARRATIVE

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ADM stated to have spoken to both of R1’s case workers and told them R1 wouldn’t be able to return to the facility due to R1’s non-ambulatory status.

ADM stated to have never issued a written or verbal eviction notice to R1. ADM stated to have told R1 that R1 would not be able to return to the facility from the hospital if R1 was no longer ambulatory because the facility does not have ramps at the entrance and exit. ADM stated R1 then chose to move into R1’s family member’s home and from there went to the hospital again.

During interview, R1’s case worker stated to have not had any record of R1 receiving an eviction notice or being given an eviction date.

Two of R1’s family members stated R1 was given a verbal eviction notice.

LPA Marrufo interviewed 7 residents. 6 out of 7 stated to have not experienced having any lice in their hair. LPA Marrufo observed the hair of 6 residents and did not observe any lice. 1 out of 7 refused to be interviewed and LPA could not observe his/her hair.

LPA Marrufo interviewed one staff who stated to have not observed any residents with lice.

The review of medical records noted nothing on lice.

ADM stated there has never been incidents of lice at the facility.

7 residents were interviewed. 1 refused to be interviewed. 4 out of 6 stated the facility is clean but they must wash their own bedsheets.

1 staff was interviewed and stated bathrooms were cleaned daily. Rooms were cleaned one at a time.
ADM stated staff clean the bathrooms every day.

Page 3 of 4.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20211214154543

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: FLORENCE RESIDENTIAL CARE HOME #2	FACILITY NUMBER: 430707868
	VISIT DATE: 12/02/2022

NARRATIVE

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LPA Marrufo observed cleaning supplies at the facility. LPA Marrufo observed 3 out of 3 bathrooms and observed them to be cleaned and the facility to be odorless during visit.

R1’s family member stated to have heard R1 complain about the facility being dirty.

Based on interviews conducted, observations, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated.

No deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Mary-Jane Ikner and a copy of this report provided.

Page 4 of 4.

END REPORT

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4