430708594-1-9-2024-26-AS-RMAO-D3LLFG-20240322084305

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708594
Report Date: 09/22/2023
Date Signed: 01/09/2024 03:24:26 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
03/13/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230313112753

FACILITY NAME:	BONHOMIE III - LENA DRIVE		FACILITY NUMBER:	430708594
ADMINISTRATOR:	ROMULDEZ, JONA		FACILITY TYPE:	740
ADDRESS:	2795 LENA DRIVE		TELEPHONE:	(408) 448-0905
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	6	CENSUS: 4	DATE:	09/22/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Jona		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff neglected a resident who had difficulty swallowing who became unresponsive and subsequently died.

INVESTIGATION FINDINGS:

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This report is being amended to remove a second allegation, questionable death, which was written erroneously.

On 09/22/2023, LPA Monter conducted an unannounced complaint investigation of the above allegations and met with Administrator, Jona

Based on the department's investigation, R1 was under hospice care with a special pureed diet. Staff (S1) who assisted in feeding R1 stated that R1 was fed one on one and watched R1 swallow with each serving. S1 denies force feeding R1. S1 stated that R1 did not show any signs of choking, difficulty swallowing, or complications. On 02/25/2023, S1 stated that he/she was feeding R1 and after 30 minute later, R1 started to make gasping noises. S1 stated that hospice care nurse arrived at the facility, stated that he/she did not observe signs that R1 choked or vomited.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BONHOMIE III - LENA DRIVE	FACILITY NUMBER: 430708594
	VISIT DATE: 09/22/2023

NARRATIVE

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Based on review of R1's autopsy records, R1's cause of death was listed as asphyxiation secondary to food aspiration. It was found that the food fed to R1 was pureed mixture of vegetable and a proteinaceous material while pathologist report states that cause of death was choking, but the manner of death was unknown. Further more, R1 did not sustain or no bruising found on the body to suspect foul play, but there was no way of telling if there was force feeding.

Based on the interviews conducted with staff and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with Administrator, Jona Romuldez and a copy of the report was provided.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
03/13/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230313112753

FACILITY NAME:	BONHOMIE III - LENA DRIVE		FACILITY NUMBER:	430708594
ADMINISTRATOR:	ROMULDEZ, JONA		FACILITY TYPE:	740
ADDRESS:	2795 LENA DRIVE		TELEPHONE:	(408) 448-0905
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	6	CENSUS: 4	DATE:	09/22/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Jona		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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A resident did not have a doctor's order for a pureed diet.

INVESTIGATION FINDINGS:

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On 09/22/2023, LPAs Monter conducted an unannounced complaint investigation of the above allegations and met with Administrator, Jona

A review of redwood hospice records shows that physicians orders for Pureed diet was effective 02/24/2023 at 1700 hours. Records also show that this updated change in diet was discussed with R1's responsible party and he/she agreed to a pureed diet.

The Department has investigated the above allegations. Based on interviews conducted and documents reviewed, the Department found the above allegations to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Exit interview was conducted with ADM Jona Romuldez and a copy of the signed report was provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 4