<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200344
Report Date: 01/23/2024
Date Signed: 01/23/2024 11:17:39 AM

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
02/22/2022 and conducted by Evaluator Simranjit Rai
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220222101527
FACILITY NAME:FORUM AT RANCHO SAN ANTONIO, THEFACILITY NUMBER:
435200344
ADMINISTRATOR:NANCY KAOFACILITY TYPE:
741
ADDRESS:23500 CRISTO REY DRIVETELEPHONE:
(650) 944-0100
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:817CENSUS: 473DATE:
01/23/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Executive Director, Nancy KaoTIME COMPLETED:
11:25 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility abandoned resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Executive Director, Nancy Kao and stated the purpose of today’s visit.

On 2/22/2022, the Department received a complaint with the above allegation. On 2/24/2022, the Department conducted an initial investigation at the facility.

On 2/14/2022, R1 was sent to the hospital due to not feeling well and R1’s child informed the facility about R1 staying in the hospital due to further tests. It was alleged that the facility refused to accept R1 back to the facility upon discharge from the hospital.

Continuation of LIC 9099-C, Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
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 2
Control Number 26-AS-20220222101527
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: FORUM AT RANCHO SAN ANTONIO, THE
FACILITY NUMBER: 435200344
VISIT DATE: 01/23/2024
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
Page 2 of 2.

On 2/24/2023, the Department conducted an interview with Administrator (ADM) who was the Assisted Living Manager at the time of interview. ADM stated R1 needed to be reassessed during the initial discharge planning by the hospital. ADM stated R1 would be admitted back to the facility as soon as R1 was ready to be picked up from the hospital.

On 10/5/2023, the Department conducted an interview with Administrator (ADM) who stated the hospital was ready to discharge resident back to assisted living facility but R1 needed to be reassessed and it was determined R1 required higher level of care and needed skilled nursing care. ADM stated R1 was going to be accepted back to the facility, but the level of care needed to be determined if R1 was appropriate for skilled nursing care or assisted living care. Based on hospital notes on 2/17/2022, hospital physician determined R1 needed post-hospital continuous nursing care and R1 would be admitted to skilled nursing facility.

Based on review of facility’s Leave of Absence form, R1 was admitted to the hospital and away from the assisted living facility from 2/14/2022 through 3/19/2022. Based on hospital’s Skilled Nursing Facility orders on 2/18/2022, resident was discharged from hospital to skilled nursing facility on 2/18/2022. Based on review of the Progress Notes from 3/19/2022, R1 was readmitted to facility’s assisted living unit under hospice services.

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 as per California Code of Regulations, Title 22. Exit interview conducted with Executive Director, Nancy Kao and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2