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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430708736
Report Date: 07/11/2024
Date Signed: 07/11/2024 12:17:37 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
08/15/2023 and conducted by Evaluator Simranjit Rai
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230815094915
FACILITY NAME:VILLA VERDEFACILITY NUMBER:
430708736
ADMINISTRATOR:JULIETA EXTRAFACILITY TYPE:
740
ADDRESS:4751 CALLE DE TOSCATELEPHONE:
(408) 978-7937
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: DATE:
07/11/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Dominica OliviaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff retained a resident with a prohibited health condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Licensee, Dominica Olivia and stated the purpose of today's visit.

On 8/15/2023, the Department received a complaint with the above allegation. On 8/16/2023, the Department conducted an initial investigation at the facility.

On 5/18/2023, R1 was assessed with a stage 2 pressure injury on the coccyx area. R1 received wound care by home health nurse. The facility staff requested R1's responsible party for additional home health visits, wound care supplies and a referral to O'Conner Hospital wound care clinic. From 5/18/2023 to 5/26/2023, the facility staff repositioned R1 every two hours. Based on review of R1's progress notes, R1's pressure injury changed in condition. On 5/26/2023, R1 went to a doctor's appointment and was admitted to the ER afterwards. The hospital doctor diagnosed the wound as a stage 4 pressure injury.
Continuation on LIC 9099-C, Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
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 5
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
08/15/2023 and conducted by Evaluator Simranjit Rai
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230815094915

FACILITY NAME:VILLA VERDEFACILITY NUMBER:
430708736
ADMINISTRATOR:JULIETA EXTRAFACILITY TYPE:
740
ADDRESS:4751 CALLE DE TOSCATELEPHONE:
(408) 978-7937
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: DATE:
07/11/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Dominica OliviaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not notify authorized representative of resident pressure injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Licensee, Dominica Olivia and stated the purpose of today's visit.

On 8/15/2023, the Department received a complaint with the above allegation. On 8/16/2023, the Department conducted an initial investigation at the facility.

Based on progress notes for R1, on 5/18/2023 at approximately 5:30am, awake night staff (S1) observed R1 to have blood during incontinence care and observed a bloody scratched blister on R1's tailbone area. During shift change, S1 informed the incoming morning shift staff (S2) about the blister. Per progress notes, S2 observed the blister and informed R1's responsible party via phone call and home health nurse was notified via phone call.

Continuation on LIC 9099-C, Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20230815094915
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: VILLA VERDE
FACILITY NUMBER: 430708736
VISIT DATE: 07/11/2024
NARRATIVE
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Page 2 of 2.

Based on interview with family member (FM1), staff S2 called FM1 on 5/18/2024 at approximately 9:00am to inform them about noticing blood during R1's incontinence care. Based on an interview with family member (FM2), staff S2 called FM1 on 5/18/2023 at 9:18am to request home health nurse to observe the wound, referring to the blister.

On 8/16/2023, the Department interviewed Licensee (LIC), who stated staff S1 called LIC at approximately 5:30am regarding R1's blister/wound and S1 informed S2 during shift change. LIC stated at approximately 8:00am, R1's responsible party was informed. LIC stated from 5/18/2023 - 5/26/2023 she was communicating with R1's responsible party via phone call to schedule an appointment with R1's primary care physician and request for home health nurse to visit R1 at the facility.

On 8/16/2023, the Department interviewed 3 staff (S1-S3), 3 out of 3 staff stated the facility staff informed R1's responsible party regarding R1's blister/wound the morning of 5/18/2023 via telephone call and requested a visit from the home health nurse.

The Department has completed the investigation of the above allegation. Based on interviews conducted and record review, the Department has found that the above allegation were UNFOUNDED, meaning the allegations were false, could not have happened and/or without a reasonable basis.

No deficiencies were cited from California Code of Regulations, Title 22 during today's visit. This report was reviewed with the Licensee, Dominica Olivia and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20230815094915
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: VILLA VERDE
FACILITY NUMBER: 430708736
VISIT DATE: 07/11/2024
NARRATIVE
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Page 2 of 2.

Based on interview with family member (FM1), R1 was taken to the hospital on 5/26/2024 after an appointment with R1's primary care doctor. O'Conner Hospital assessed R1's wound on coccyx as a stage 4 pressure injury.

Based on interview with family member (FM2), on 5/18/2024, home health nurse visit R1 at the facility and the wound near the tailbone was measured as a stage 2 wound. On 5/22/2023, FM1 spoke with home health nurse and stated R1's wound was stage 2 and the wound would continue to be treated with Tera Honey and bandaged. On 5/23/2023, the condition of the wound changed where the wound was described as "yellow with pus discharge". On 5/24/2023, the home health Physical Therapist (PT) observed the wound was growing bigger and now was a "deep hole with oozing pus". On 5/26/2023, FM1 transported R1 to R1's doctor's appointment where R1's primary care physician advised R1 to be taken to the Emergency Room immediately. On 5/27/2024, after R1 was diagnosed with stage 4 pressure injury, R1 underwent surgery for the wound.

Based on review of R1's progress notes, On 5/23/2023, staff noticed R1's wound changed condition and on 5/26/2023, R1 received medication attention and wound was assessed as a stage 4 pressure injury.

On 11/16/2023, the Department conducted an interview with the Licensee (LIC). LIC stated the facility can only keep a resident with a stage 2 wound and if the wound worsens to anything above a stage 2, the resident will need to be transported to the hospital for an evaluation. LIC stated R1 was not under Hospice services.

The Department has completed the investigation of the above allegation. Based on interviews and record review, the preponderance of evidence standard as been met therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today's visit, see LIC 9099-D.

This report was reviewed with Licensee, Dominica Olivia and a copy of the report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20230815094915
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: VILLA VERDE
FACILITY NUMBER: 430708736
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2024
Section Cited
CCR
87615(a)(1)
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87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly(1) Stage 3 and 4 pressure injuries.
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Licensee will provide a written plan of action understanding the regulation and ensure residents with wounds are assessed to determine if the wound has developed into stage 3 and stage 4 and appropriate measures are taken. Licensee agreed and understood.
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This requirement was not met as evidenced by: Based on record review and interview, R1 was residing at the facility from 5/23 -5/26/2023 with a change of condition of the stage 2 pressure injury and became a stage 4 pressure injury which poses/posed an immediate Health, Safety, or Personal..
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(con't) Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5