430708150-6-21-2023-26-AS-KHOS-CTDKFU-20230703075232

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708150
Report Date: 06/21/2023
Date Signed: 06/21/2023 03:26:13 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
06/22/2020 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20200622143406

FACILITY NAME:	COLLEGE MANOR		FACILITY NUMBER:	430708150
ADMINISTRATOR:	CORA REYES		FACILITY TYPE:	740
ADDRESS:	760 LEIGH AVENUE		TELEPHONE:	(408) 293-3745
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	6	CENSUS: 6	DATE:	06/21/2023
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Dominica Oliva		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff made false claims against resident.
Facility is unable to meet resident's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced complaint visit to deliver the investigation finding for the above allegations. LPA met with Licensee, Dominica Oliva.

On 06/22/2020, the Department received a complaint alleging resident (R1) was hurt by a staff who allegedly made false claims by stating R1 had bit themselves and attacked staff. It was also alleged that staff do not know how to handle residents with a neurocognitive condition and aggressive behaviors.

On 06/30/2020, LPA Karen Taku conducted the initial 10-day complaint investigation virtually. Due to the COVID-19 Pandemic, the Department had suspended on-site visits for preventative measures. LPA Taku requested the followng documents to include a copy of staff and resident rosters, staff training logs, and resident (R1-R3) records. Emergency Contact Form, Physician's Report, Appraisal/Needs and Services Plan, and Functional Capabilities Assessment for R1-R3. 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: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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-20200622143406

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: COLLEGE MANOR	FACILITY NUMBER: 430708150
	VISIT DATE: 06/21/2023

NARRATIVE

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On 05/25/2023, LPA Dolores arrived at the facility unannounced to continue the complaint investigation. During visit LPA reviewed resident (R1)'s file to include only reports from 2014 - 2019. From 05/25/2023 - 06/02/2023, documents were obtained to include resident roster, R1's physician's report, skin / office visit sheet, and training records.

Based on interview and record review, R1 had passed away in September 2020.

The review of records indicates on 06/17/2020, R1 became agitated and combative and was transported by ambulance to the emergency room per physician’s instructions. Records show that upon EMS arrival, R1 was not combative or agitated with EMS crew but R1 stated facility staff was trying to hurt him/her.

On 05/25/2023, 4 staff members were interviewed. Based on interview, R1 was diagnosed with a neurocognitive condition and was known to have aggressive behavior. Staff explained their process to first give R1 space and then to come back later to try again. 4 out of 4 staff stated R1 did not have self injurious behaviors to include biting of the skin. 4 out of 4 staff stated R1 was alert and verbal about his/her concerns and needs. 4 out of 4 staff denied a staff hurting and/or attacking R1.

From 06/01/2023 – 06/06/2023, 2 witnesses (W1 – W2) was interviewed. Based on interview with W1, R1 never had behaviors of biting oneself. R1 was described to be verbally expressive. W1 states R1 displayed aggressive behavior towards individuals he/she may not be comfortable with. W1-W2 believe staff were trained to the meet the needs of the resident and trained to handle residents with aggressive behaviors.

Based on review of the staff training records, the facility provided training from February 2020 – April 2020 in topics to include but not limited to understanding dementia and types of elder abuse.

The Department has investigated the above allegations. Based on interview, record review, and observation the Department has investigated the above allegations are unsubstantiated. An unsubstantiated finding means although the allegations may have happened and/or is valid there is 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 Licensee, Dominica Oliva 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: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

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