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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430708594
Report Date: 02/20/2024
Date Signed: 02/21/2024 08:08:55 AM

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
03/13/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20230313112753
FACILITY NAME:BONHOMIE III - LENA DRIVEFACILITY NUMBER:
430708594
ADMINISTRATOR:ROMULDEZ, JONAFACILITY TYPE:
740
ADDRESS:2795 LENA DRIVETELEPHONE:
(408) 448-0905
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 5DATE:
02/20/2024
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Gladys SmartTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Resident eloped from the facility.
Facility did not have awake night staff for hospice residents.
Facility dinner meals have been reduced in both quantity and quality.
Residents are losing weight.
Residents who requires feeding had to wait for attention due to only one staff assisting during meals.
Facility staff left residents without supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Administrator (ADM) Gladys Smart.

On 03/13/2023, the Department received a complaint with the above allegations.

On 03/14/2023, the Department conducted an initial investigation visit. LPAs requested the following documents: resident physician report, appraisal needs and service plan, incident reports, menu, schedule of staff and staff training documents.

On 9/22/2023, the Department delivered the investigation findings for the allegations that staff neglected a resident who had difficulty swallowing who became unresponsive and subsequently died, and A resident did not have a doctor's order for a pureed diet.
Continue on LIC9099-C. Page 1 of 4.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
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-20230313112753
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: BONHOMIE III - LENA DRIVE
FACILITY NUMBER: 430708594
VISIT DATE: 02/20/2024
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Resident eloped from the facility:
Facility staff left residents without supervision.
On 06/14/2023, the Department interviewed 3 residents. 3 out of 3 residents stated there are no issues or concerns for the facility.

On 01/19/2024, the Department interviewed 3 residents. 3 out of 3 residents stated the facility never left residents unattended, and the facility always has staff in the facility. The Department interviewed 2 staff (S2, S3). 2 out of 2 stated the facility always has staff in the facility, and never left residents unattended. S2 stated he/she never saw or heard any resident eloped from the facility. The Department interviewed Administrator (ADM). ADM denied there was any resident eloped from the facility. ADM stated the facility has staff 24 hours a day. ADM stated staff sometimes took residents to backyard for fresh air, but never left residents unattended.

The Department did not received any incident report or cross report that the facility resident eloped from the facility. Based on the interviews, the facility never left residents unattended, and there was no resident eloped from the facility. Facility resident were never left without supervision.

Facility did not have awake night staff for hospice residents:
On 1/19/2024, the Department interviewed 3 residents. 1 out of 3 residents stated the facility has staff 24 hours a day. 1 out of 3 residents stated that the staff helped him/her to go to restroom at night. The Department interviewed ADM and 2 staff. 3 out of 3 staff confirmed the facility has an awake staff at night shift.

Reviewing the facility staff schedule. the facility always has a staff on duty at night shift.

Based on the interviews with residents and staff, and documents, the facility has an awake staff at night shift.

Continue on LIC9099-C. Page 2 of 4.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20230313112753
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: BONHOMIE III - LENA DRIVE
FACILITY NUMBER: 430708594
VISIT DATE: 02/20/2024
NARRATIVE
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Facility dinner meals have been reduced in both quantity and quality:
On 1/9/2024, the Department interviewed 3 residents. 3 out 3 residents stated the facility provides enough food for the meals, and they can request more if they want. 1 out of 3 residents stated if he/she does not like the food that the facility provides, he can request to change. The Department interviewed ADM and 2 staff (S2, S3). 3 out of 3 staff stated the facility provides plenty of food for the meals, and the residents can request second round of food if they want more. S2 stated the facility prepares the food based on the residents' preference, they cook the food which the residents like. ADM stated the home provides the residents with their plates. ADM stated the home provides vegetables, carbohydrates and protein with quality. ADM stated there are two staff during the meals time to help residents for meals. ADM provided the facility food menus.

Based on the interviews with residents and staff, there is no evidence the facility dinner meals have been reduced in quantity and quality.

Residents are losing weight:
on 1/9/2024, the Department interviewed ADM and 2 staff . Both staff stated if any resident lost weight they will report to ADM, doctor and family. ADM stated he/she will report to doctor and family if resident lost weight. There are two staff during the meal time, and the staff will help to feed the residents. ADM stated he/she did not find resident lost weight significantly except resident R1. R1 was on hospice care and had swallowing difficulty problem. ADM stated according to the hospice doctor instruction, if R1 refuses to eat or coughing, then staff to stop feeding R1 because of safety issue. ADM stated the doctor was ware of R1 losing weight.

ADM stated the facility staff followed the doctor's instruction to feed and take care of R1. ADM provided other residents weight records. ADM stated the doctor issued a doctor order to provide R1 pureed food because R1's losing weight and having difficult of swallowing.

Based on interviews and records reviewed, there was no evidence to indicate that the facility had fault causing resident losing weight.

Continue on LIC9099-C. Page 3 of 4.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20230313112753
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: BONHOMIE III - LENA DRIVE
FACILITY NUMBER: 430708594
VISIT DATE: 02/20/2024
NARRATIVE
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Residents who requires feeding had to wait for attention due to only one staff assisting during meals:

On 1/9/2024, the Department interviewed ADM and 2 staff. 3 out of 3 staff stated there are always 2 staff during the meal time to help residents for meals, residents do not need wait for eating. Resident R4 stated residents do not need to wait, the staff help right away.

Reviewing the facility staff schedule, there are always two staff during the breakfast, lunch and dinner time.

Based on interviews and record reviewed, resident who needs feeding assistance does not need to wait for meals.


Based on observations, documents review, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

No citations noted at today’s compliant investigation visit.

Exit interview conducted with ADM. A copy of this report was provided to ADM.


Page 4.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4