430708817-7-11-2023-26-AS-RMAO-CU4N7E-20230726101238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708817
Report Date: 07/11/2023
Date Signed: 07/11/2023 06:12:42 PM

Unfounded

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
05/12/2020 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20200512124045

FACILITY NAME:	TERRACES OF LOS GATOS, THE		FACILITY NUMBER:	430708817
ADMINISTRATOR:	BURGOYNE, BRADLEY		FACILITY TYPE:	741
ADDRESS:	800 BLOSSOM HILL ROAD		TELEPHONE:	(408) 356-1006
CITY:	LOS GATOS	STATE: CA	ZIP CODE:	95032
CAPACITY:	458	CENSUS: 287	DATE:	07/11/2023
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Director of Resident Services, Sandra Mirasol Director of Assisted Living and Wellness, Charmaine Verador		TIME COMPLETED:	06:20 PM

ALLEGATION(S):

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Staff will not provide responsible party with resident's medical records

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simranjit (Simi) Rai and LPM Romeo Manzano conducted an unannounced complaint visit today to deliver the investigation findings on the above allegation. LPA and LPM spoke with Executive Director (ED) Bradley Burgoyne.

On 05/12/20, the department received a complaint with the allegation that the facility staff will not provide responsible party (RP) with resident’s medical records.

On 05/26/20, LPA Larios conducted an initial 10-day investigation. ED was interviewed and LPA requested resident’s documents which facility provided on 05/29/20.

Continued on LIC9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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-20200512124045

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: TERRACES OF LOS GATOS, THE	FACILITY NUMBER: 430708817
	VISIT DATE: 07/11/2023

NARRATIVE

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On 06/16/20, LPA interviewed staff at the facility and subsequently requested for documents of the facility’s correspondence with R1’s responsible party (RP). On 06/17/20, the facility provided the department with correspondence information they have provided to R1's RP.

Between 10/02/20 and 11/23/20, the department obtained from RP, records of correspondence information between RP and the facility.

Based on records review, RP signed a request form to access resident’s medical records on 04/25/20 and re-submitted a copy to the facility on 05/12/2020 as RP has not received R1's medical records from the facility. The request was dated from the resident’s admission date of 01/15/20 up to 12/31/20 (present). RP also provided a signed authorization form from R1’s doctor, for use or disclosure of resident’s health information.
The form authorizes the facility to release all health information to RP pertaining to R1’s medical history, mental or physical condition and treatment received. As of the date of the complaint (05/12/20), the facility has only provided RP with resident’s medical records between 04/24/20 until 05/02/20.

Based on a review of the facility's policy on medical records request, the facility has to notify their Legal/Risk Management Team wherein the facility did not refer this request which should have been handled accordingly hence the documents being released were incomplete and/or incorrect documents. The Garden Grove Director and the Resident Services Director had ongoing communication with the RP in various emails with ED and management team. ED stated, "... that any delays were certainly not intentional, as our fullest attention was providing direct care for the resident .."
After a month from the date it was requested, R1's medical records were provided to R1's RP on 05/15/2020.

This agency has investigated the complaint allegation listed. Based on interviews, review of records, and observations, the Department has found that the complaint allegation is unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

This report was reviewed with and signed by Charmaine Verador and Sandy Mirasol. A copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC9099 (FAS) - (06/04)

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