435200605-10-16-2024-26-AS-KHOS-DABPLW-20241023112526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200605
Report Date: 10/16/2024
Date Signed: 10/16/2024 11:28:51 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
12/20/2022 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20221220120523

FACILITY NAME:	ATRIA WILLOW GLEN		FACILITY NUMBER:	435200605
ADMINISTRATOR:	GURSU, UGUR (KURT)		FACILITY TYPE:	740
ADDRESS:	1660 GATON DR		TELEPHONE:	(408) 266-1660
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	63	CENSUS: 55	DATE:	10/16/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Trever Treadwell, Resident Services Director.		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Staff do not provide resident with housekeeping
Staff do not assist resident with grooming
Staff locks resident inside of resident's living unit

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Trever Treadwell, Resident Services Director.

On March 16, 2023, the Department received a complaint alleging Staff do not provide resident with housekeeping.

On August 7, 2024, LPA interviewed residents R2-R6. 3 Out of 5 residents (R2-R4) stated their bedroom is cleaned everyday and they have not observed other bedrooms are dirty/unkempt. Resident R5 was unable to provide LPA answer and would digress to unrelated topics. Resident R6 declined to be interviewed.

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: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

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-20221220120523

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 10/16/2024

NARRATIVE

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On August 7, and September 10, 2024, LPA interviewed staff S1-S8. 7 Out of 8 staff (S1-S2, S4-S8) interviewed stated facility staff enters resident bedrooms at least two times per shift. 6 Out of 7 staff (S1-S2, S4-S8) stated if a resident’s room is observed as not clean, staff will clean the bedroom. 5 Out of 8 staff stated the residents’ bedrooms are cleaned daily and house keeping cleans weekly.

On September 20, 2023, August 7, September 10 and September 16, 2024, the Department conducted unannounced visits to the facility. LPA Monter observed the following bedrooms: as clean and sanitary (5,9,20,21,24,25,29,30, CE25, CE24, CE1, CE5, CE9, CE4). LPA Monter did not observe any resident bedroom as dirty or unsanitary.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records 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.

Staff do not assist resident with grooming

On March 16, 2023, the Department received a complaint alleging Staff do not assist resident with grooming.

On August 7, 2024, LPA interviewed residents R2-R6. 2 Out of 5 residents (R2-R3) interviewed stated, they do their own grooming, but staff will assist if asked. Resident R4 stated he/she receives assistance with Grooming. 3 Out of 6 residents interviewed (R2-R4) stated they have not seen other residents dirty or in a disheveled state. Resident R5 was unable to provide LPA answer and would digress to unrelated topics. Resident R6 declined to be interviewed.

On August 7, and September 10, 2024, LPA interviewed staff S1-S8. 7 Out of 8 staff (S1-S2, S4-S8) stated if a resident is seen dirty or in a disheveled state, staff will immediately help clean them up. 8 Out of 8 staff interviewed stated staff helps residents with their daily grooming. 8 Out of 8 staff stated they have not seen a resident in a disheveled state.

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: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20221220120523

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 10/16/2024

NARRATIVE

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On September 20, 2023, August 7, September 10 and September 16, 2024, the Department conducted unannounced visits to the facility. LPA Monter did not observe any residents who were not groomed or in a disheveled state.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records 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.

Staff locks resident inside of resident's living unit

On March 16, 2023, the Department received a complaint alleging Staff locks resident inside of resident's living unit.

On August 7, 2024, LPA interviewed residents R2-R6. 3 Out of 5 residents (R2-R4) stated staff don’t lock residents inside their rooms. 3 Out of 5 (R2-R4) residents interviewed stated they can unlock their bedroom door by twisting the doorknob. Resident R5 was unable to provide LPA answer and would digress to unrelated topics. Resident R6 declined to be interviewed.

On August 7, and September 10, 2024, LPA interviewed staff S1-S8. 8 Out of 8 staff interviewed stated staff don’t lock residents inside their bedrooms. 8 Out of 8 staff interviewed stated residents can twist the doorknob and the door can open.

On September 20, 2023, LPA Monter toured the Memory care unit. LPA observed resident bedroom doorknobs can unlock from the inside by twisting the doorknob. LPA did not observe any other locking mechanism on the door besides the doorknob.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records 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.

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: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC9099 (FAS) - (06/04)

Page: 3 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
12/20/2022 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20221220120523

FACILITY NAME:	ATRIA WILLOW GLEN		FACILITY NUMBER:	435200605
ADMINISTRATOR:	GURSU, UGUR (KURT)		FACILITY TYPE:	740
ADDRESS:	1660 GATON DR		TELEPHONE:	(408) 266-1660
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	63	CENSUS: 55	DATE:	10/16/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Trever Treadwell, Resident Services Director.		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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8
9

Staff do not meet resident's incontinence needs
Staff do not monitor resident for change in condition

INVESTIGATION FINDINGS:

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On March 16, 2023, the Department received a complaint alleging Staff do not meet resident's incontinence needs. It has been alleged the facility did not meet R1’s toileting needs.

On August 7, 2024, LPA interviewed residents R2-R6. 3 Out of 5 residents (R2, R3, R4) interviewed stated they don’t need assistance with toileting, but staff will assist them if they request. Resident R5 was unable to provide LPA answer and would digress to unrelated topics. Resident R6 declined to be interviewed.

LPA interviewed staff S1-S6. 6 Out of 6 staff interviewed stated staff assist residents with their toileting needs. 4 Out of 6 staff interviewed (S1, S2, S5, S6), stated staff check and ask residents if they need to use the restroom. Staff S1-S3 stated they remember R1 but do not remember working with him/her. S4-S6 stated they are new employees and had no interactions with R1.

Page 1 Out of 3.

Unsubstantiated

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: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20221220120523

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 10/16/2024

NARRATIVE

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Based on a Review of R1’s Physicians Report, dated July 19, 2022, resident R1 does not have bowel or bladder impairment. Furthermore, the report states R1 is able to care for his/her own toileting needs.

The Department reviewed R1’s Resident Functional needs Assessment, dated October 18, 2022. The assessment states R1 requires limited assistance, wherein the facility would escort R1 to the bathroom 6 times per day.

Based on a review of Facility Progress Notes, dated October 5, 2022, stated R1 is now incontinent. The Note states the facility implemented 3-hour toileting but R1 would be placed on the toilet but R1 would did not have a bowel/bladder movement. The note stated R1 would then use the restroom on the floor 10 minutes later.

The Department was unable to interview Resident R1, who no longer lives at the facility.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Staff do not monitor resident for change in condition

On March 16, 2023, the Department received a complaint alleging Staff do not monitor resident for change in condition. Its been alleged that the facility staff did not know R1 had a Urinary Tract Infection (UTI).

On December 22, 2022, LPA Marrufo interviewed Witness (W1). W1 stated he/she was informed by the facility regarding the UTI. W1 stated, the director told him/her a care giver had observed blood in R1’s urine.

On August 7, 2024, LPA interviewed staff S1-S6. 4 Out of 6 staff interviewed (S1, S2, S4, S5) stated when shifts change, the leaving shift informs the upcoming shift of any changes of conditions they observed during their shift. 5 Out of 6 staff interviewed stated when they observe a change of condition, they will inform the medtech/Memory care director. Staff S1-S3 stated they remember R1 but do not remember working with him/her. S4-S6 stated they are new employees and had no interactions with R1. 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: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 26-AS-20221220120523

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 10/16/2024

NARRATIVE

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Based on record review, there is no incident report regarding R1 having a UTI.

Based on a review of R1’s Resident Diagnosis Management form, dated September 23, 2024, the form does not indicate that R1 had a diagnosis of a UTI, during his/her stay at the facility.

According to Mayo Clinic (https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447), UTIs don't always cause symptoms. When they do, they may include: … Urine that appears red, bright pink or cola-colored — signs of blood in the urine.

The Department was unable to interview Resident R1, who no longer lives at the facility.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Page 3 Out of 3. END OF REPORT.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 6