435200192-1-19-2024-26-AS-RMAO-CZW4ZJ-20240127183249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200192
Report Date: 01/19/2024
Date Signed: 01/19/2024 03:56:55 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
12/21/2022 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20221221131344

FACILITY NAME:	OLGA'S CARE HOME FOR THE ELDERLY		FACILITY NUMBER:	435200192
ADMINISTRATOR:	ATIENZA-BILAN, OLGA		FACILITY TYPE:	740
ADDRESS:	954 JUNESONG WAY		TELEPHONE:	(408) 272-7040
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95133
CAPACITY:	6	CENSUS:	DATE:	01/19/2024
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Administrator Atienza-Bilan		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff physically abuses resident
Facility staff yells at resident
Facility staff deprives resident of food
Unqualified Staff

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA met with facility Administrator (ADM) Atienza-Bilan.

On December 21, 2022, the department received a complaint alleging facility staff yells/physically abuses resident R1. It has also been alleged facility staff deprive resident R1 of food.

On December 26, 2023, the department interviewed ADM Olga Atienza-Bilan. ADM denied the allegations and stated he/she does not hit/yell at the residents. ADM stated he/she does not deprive residents’ food. ADM stated R1 has mental disorder and makes up stories.

On January 13, 2024, LPA Manuel Monter interviewed 5 residents. (R1-R5). 5 Out of 5 residents denied the allegations and stated the staff don’t hit or yell at residents. 5 Out of 5 residents stated facility staff don’t deprive residents of food. Page 1 Out of 3.

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: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

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 6

Control Number 26-AS-20221221131344

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: OLGA'S CARE HOME FOR THE ELDERLY	FACILITY NUMBER: 435200192
	VISIT DATE: 01/19/2024

NARRATIVE

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On January 13, 2024, LPA Monter interviewed S1. S1 denied the allegations and stated staff don’t hit/yell at residents. S1 stated the staff don’t deprive residents’ food.

Based on a review of R1’s physician’s report dated October 29, 2022, R1 has a mental disorder.

Based on a review of R1’s Appraisal Needs & Services Plan, dated February 2, 2023, R1 has a mental disorder.

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

No deficiencies cited, Exit interview conducted with Administrator, Atienza-Bilan and a copy of the report was provided.

Unqualified Staff

On December 21, 2022 the department received a complaint alleging staff is unqualified.

On December 26, 2023, the department requested staff training documents from ADM.

The department reviewed staff training records for Olga’s Care Home For the Elderly. Staff S1-S4 had 10-12 training certificate forms. Staff S1-S4 completed training in the following, but not limited to; ADL's personal care of residents, food prep, medication, resident's rights, bladder/bowel incontinence, dementia, & abuse reporting.

The department also reviewed the ADM's training records. The ADM had training on the following, but not limited to; Dementia training, medication training, fall prevention, infection control, DSS laws regulations & polices, Nutrition and working with Hospice.

Page 2 Out of 3

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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
12/21/2022 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20221221131344

FACILITY NAME:	OLGA'S CARE HOME FOR THE ELDERLY		FACILITY NUMBER:	435200192
ADMINISTRATOR:	ATIENZA-BILAN, OLGA		FACILITY TYPE:	740
ADDRESS:	954 JUNESONG WAY		TELEPHONE:	(408) 272-7040
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95133
CAPACITY:	6	CENSUS: 5	DATE:	01/19/2024
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Administrator Atienza-Bilan		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff did not report abuse of resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA met with facility Administrator (ADM) Atienza-Bilan.

On December 21, 2022 the department received a complaint alleging staff did not report abuse of resident.

On December 26, 2023, Licensing Program Manager (LPM) Romeo Manzano interviewed ADM. ADM stated, "When R1 told me about what he/she told the nurse about me hitting him/her... I did not report to licensing." LPM asked if ADM filed SOC341, ADM was not sure what an SOC341 was. LPM explained to ADM about mandated reporting duties. ADM stated, " i did not report because it wasn't true. Now I understand that I have to report whether its true or not. "

Page 1 out of 2.

Substantiated

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: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

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

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 26-AS-20221221131344

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: OLGA'S CARE HOME FOR THE ELDERLY	FACILITY NUMBER: 435200192
	VISIT DATE: 01/19/2024

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on interviews conducted, the preponderance of evidence standard has 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 Administrator Atienza-Bilan and a copy of the report was provided. Appeal Rights was provided. Page 2 out of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20221221131344

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: OLGA'S CARE HOME FOR THE ELDERLY	FACILITY NUMBER: 435200192
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/26/2024 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211(a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by;	1 2 3 4 5 6 7	LPA discussed Reporting requirements and SOC341 with ADM. ADM stated she would send letter of understanding regarding regulation. ADM stated she would send letter by POC date, January 26, 2024.
	8 9 10 11 12 13 14	Based on interview with ADM. ADM stated he/she did not report when R1 told ADM about the alleged abuse. ADM stated he/she did not report to licensing. This poses a potential health, safety or personal rights risk to persons 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: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 26-AS-20221221131344

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: OLGA'S CARE HOME FOR THE ELDERLY	FACILITY NUMBER: 435200192
	VISIT DATE: 01/19/2024

NARRATIVE

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

No deficiencies cited, Exit interview conducted with Administrator, Atienza-Bilan and a copy of the report was provided. Page 3 Out of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 6