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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200344
Report Date: 12/23/2025
Date Signed: 12/23/2025 04:36:44 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
09/24/2025 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20250924132416
FACILITY NAME:FORUM AT RANCHO SAN ANTONIO, THEFACILITY NUMBER:
435200344
ADMINISTRATOR:ROSALIE B ZBASNIK-HULOGFACILITY TYPE:
741
ADDRESS:23500 CRISTO REY DRIVETELEPHONE:
(650) 944-0100
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:817CENSUS: 518DATE:
12/23/2025
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Rosalie HulogTIME COMPLETED:
04:38 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is not being assessed for injuries after fall.
Facility staff left resident on the floor after calling 911.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Director of Health Services Rosalie Hulog (DHS).

On 09/24/2025, the Department received a complaint with the above allegations.

On 10/01/2025, an initial investigation visit was conducted.

LPA interviewed DHS, 3 staff and resident R1.

Incident report, physician report, and appraisal/Needs and service plan of R1 were obtained.

Continue on LIC(099-C, Page 1 of 3.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
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 3
Control Number 26-AS-20250924132416
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: 12/23/2025
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
Resident is not being assessed for injuries after fall:
Facility staff left resident on the floor after calling 911:
On 10/01/2025, LPA interviewed Director of Health Service (DHS) Rosalie Hulog and Memory Care Manager. Both stated the facility policy is that caregivers are not allowed to move residents when they find residents were on the floor. The caregivers need to call nurses first (if nurse is busy, caregivers need to call Med Tech to come). Both stated the nurses check/evaluate resident on the floor and call 911 immediately. Both stated nurses check resident visually only. Both stated nurses cannot move the residents on the floor until paramedics come on site to evaluate the residents. Both stated nurses check if resident on the floor painful, bleeding, and check the vital signs. Both stated the nurses need to prepare the resident's document and to answer the questions from paramedics to help residents to be sent to hospitals. Both stated the policy was instructed to staff during the staff training.

ON 10/01/2025, LPA interviewed the facility staff LVN (S1). S1 stated on 9/22/2025, he/she was notified by a caregiver that memory care unit resident R1 was found on the floor in R1's bedroom. S1 stated he/she went on site of R1's bedroom. S1 stated he/she called 911, evaluated R1 and prepared R1's document to be sent to hospital. S1 stated the facility's policy is not to move residents who are found on the floor. S1 stated another caregiver S2 was with him/her on site to take care and monitor R1.

LPA interviewed caregiver S2. S2 stated he/she was notified on the floor in R1's room by another caregiver. S2 stated when he/she was on site at R1's room, S1 already there. S2 stated he/she observed S1 assessed R1 and prepared R1's document for the emergency room. S2 stated R1 stated he/she was fine but legs were numbed. S2 stated the facility policy is not to move residents who are found on the floor.

Based on the review of the incident report dated 9/2325, R1's vital signs were 120/57 for blood pressure, 98.2 for temperature, 80 for pulse, 18 for respiratory rate, and 98% for oxygen.

Based on the review of the facility policy of fall, it specifies do not move or lift an individual off the ground until it's verbalized that there's no pain and able to get up with minimum support and able to bear weight and ambulate.

Continue on LIC9099-C. Page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20250924132416
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: 12/23/2025
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
The Department has investigated the above allegation. Based on the interview and record reviewed, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citation noted today. Exit interview was conducted with DHS. The report was provided to DHS for signature. A copy of the report was provided to DHS.

Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3