430708724-2-23-2023-26-AS-KHOS-CRFHDM-20230502060635

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708724
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:36:10 PM

Substantiated

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
10/08/2020 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20201008163105

FACILITY NAME:	LINCOLN & PINE, WILLOW GLEN		FACILITY NUMBER:	430708724
ADMINISTRATOR:	LIGAYA SEMANA		FACILITY TYPE:	740
ADDRESS:	1710 LINCOLN AVENUE		TELEPHONE:	(408) 265-6520
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	6	CENSUS: 6	DATE:	02/23/2023
		UNANNOUNCED	TIME BEGAN:	11:09 AM
MET WITH:	Gladys Smart		TIME COMPLETED:	03:39 PM

ALLEGATION(S):

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Resident left the facility unsupervised and sustained injuries

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced complaint investigation to deliver findings on the above allegtaion. LPA met with facility Administrator Gladys Smart (Admin).

During interview conducted with Admin on 10/15/2020, S1 confirmed that a resident (R1) had eloped from the facility on 09/27/2020. Admin stated that they believed that staff member on duty was asleep at the time of R1's elopement. Review of incident report indicated that the elopement occurred at an underermined time on 09/27/2020, but was discovered at 12:00am. R1 was found by staff 45 minutes later and returned to the facility. In review of R1's physician's report, it was determined that R1 was not permitted to leave the facility unassisted.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

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-20201008163105

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: LINCOLN & PINE, WILLOW GLEN	FACILITY NUMBER: 430708724
	VISIT DATE: 02/23/2023

NARRATIVE

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During tour of the facility on 10/15/2020, facility door alarms were determined to be functioning properly. LPA toured the facility and tested all the door alarms once more. All alarms were observed to be functioning properly. In review of staff training documents, it was determined that staff have received additional training regarding care for residents with dementia and wandering tendencies.

In review of photographic evidence submitted by a witness and facility incident report written regarding the elopement, it is confirmed that R1 sustained a bump on their head as well as bruising around the eye during the period in which R1 was not on the premises.

The Department has conducted an investigation of the above allegation. Based on interviews conducted and records review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Deficiency is being cited. Civil penalty Assessed. See LIC 9099-D and LIC421IM.

Exit interview conducted with Administrator Gladys Smart. A copy of this report, along with the facility's appeals rights were provided electronically due to printer error.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20201008163105

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: LINCOLN & PINE, WILLOW GLEN	FACILITY NUMBER: 430708724
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/24/2023 Section Cited CCR 87705(c)(4)(A)	1 2 3 4 5 6 7	87705 - Care for Persons with Dementia - (c)(4)(A) a facility... shall have at least one night staff person awake and on duty if any resident with dementia is determined... to require awake night supervision. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	POC has already been received
	8 9 10 11 12 13 14	Based on interviews and records reviewed, the facility did not prevent resident elopement due to night shift staff member sleeping during his/her shift. This posed an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC9099 (FAS) - (06/04)

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