435200334-4-4-2024-26-AS-KHOS-D4ENTQ-20240417104504

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200334
Report Date: 04/04/2024
Date Signed: 04/04/2024 03:38:48 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
08/15/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230815165012

FACILITY NAME:	PRINCESS CARE HOME #4		FACILITY NUMBER:	435200334
ADMINISTRATOR:	JUDITH MORALES		FACILITY TYPE:	740
ADDRESS:	1537 ILIKAI		TELEPHONE:	(408) 264-1240
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	6	CENSUS: 0	DATE:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	House Manager, Randi Cabrera		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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9

Facility staff does not administer medication.
Facility staff withholding resident's clothes.

INVESTIGATION FINDINGS:

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13

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: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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 4

Control Number 26-AS-20230815165012

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: PRINCESS CARE HOME #4	FACILITY NUMBER: 435200334
	VISIT DATE: 04/04/2024

NARRATIVE

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Facility staff do not administer medication
On 8/9/2023, resident (R1) was moved from another facility and was admitted to this facility before 5pm. Based on review of R1’s Medication Administration Record (MAR) for August 2023, R1 was administered prescribed medications and facility staff documented resident refusing medications. Based on review of R1’s prescribed medications on Hospice Care Plan and LIC 621 Centrally Stored Medication and Destruction Record, R1 was administered medications as prescribed by physician.

On 8/23/2023, the Department interviewed 3 staff at the facility. 3 Out of 3 staff stated the resident was administered medication as prescribed by physician. Based on review of R1’s Hospice notes, R1 was administered PRN medication during visits and hospice staff observed facility staff administering medication during their visits.

Facility staff withholding resident’s clothes
It was alleged the staff were not giving R1 clothes and restricting access to R1’s clothes. Based on review R1’s LIC 621 Client/Resident Personal Property & Valuables signed by R1’s Responsible Party, R1 had 11 personal items which were placed in the facility on 8/9/2023 and the same 11 personal items were removed on 8/21/2023 after R1 passed away. R1’s Responsible Party and facility staff signed and acknowledged each personal item.

On 8/23/2023, the Department interviewed 3 staff at the facility. Two staff worked closely with R1, 2 out of 2 staff stated R1 had access to clothes in R1’s room and facility staff did not restrict R1’s access to the clothes. Staff FM1 stated the facility did not have issues of residents’ clothes being misplaced or stolen at the facility. Staff FM1 stated R1’s clothes were labeled and accounted for on LIC 621 Client/Resident Personal Property & Valuables form.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, 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 from California Code of Regulations, Title 22. Exit interview conducted with Administrator and 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: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

Page: 2 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
08/15/2023 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230815165012

FACILITY NAME:	PRINCESS CARE HOME #4		FACILITY NUMBER:	435200334
ADMINISTRATOR:	JUDITH MORALES		FACILITY TYPE:	740
ADDRESS:	1537 ILIKAI		TELEPHONE:	(408) 264-1240
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	6	CENSUS: 0	DATE:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	House Manager, Randi Cabrera		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff being rough when providing care to resident

INVESTIGATION FINDINGS:

1
2
3
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5
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the House Manager, Randi Cabrera and stated the purpose of today’s visit.

On 8/15/2023, the Department received a complaint with the above allegations. On 8/23/2023, the Department conducted an initial investigation at the facility.

It was alleged that the facility staff “hurts” clients when they move her. R1 was observed to have pain symptoms at the facility. Based on review of R1’s Hospice notes, R1 was in pain 3 out of 8 visits and Hospice RN administered pain medications. Based on review R1’s Medication Administration Records (MAR) for August 2023, R1 was being administered 2 different pain medications 3 times a day.

Continuation on LIC 9099-C, Page 1 of 2.

Unsubstantiated

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: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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 4

Control Number 26-AS-20230815165012

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: PRINCESS CARE HOME #4	FACILITY NUMBER: 435200334
	VISIT DATE: 04/04/2024

NARRATIVE

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Page 2 of 2.
Based on review of R1’s PRN form for August 2023, R1 was administered pain medication as needed 9 out of the 10 days R1 was admitted at the facility.

R1 was moved by facility staff when R1 was provided care. Based on review of R1’s Appraisal/ Needs and Services Plan dated 8/15/2023 under "Physical/ Health" R1 "needs maximum assistance with his/her transfer from bed to wheelchair, wheelchair to bathroom and vice versa". On 8/23/2023, the Department interviewed 3 staff at the facility. Staff S1 stated “facility staff ae not bring rough when providing care to the resident”. 2 out of 3 staff stated R1 always had pain, which required two staff to assist R1.

Based on the interviews conducted with clients and staff and based on observation 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.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and 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: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4