435200605-10-16-2024-26-AS-KHOS-DABQ7E-20241023115500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200605
Report Date: 10/16/2024
Date Signed: 10/16/2024 11:34:02 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
07/30/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240730121919

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:	11:40 AM

ALLEGATION(S):

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A resident's toilet is in disrepair
Neglect/lack of supervision resulted in resident eloping.
Facility door alarm is in disrepair
Facility did not notify residents responsible party/CCLD regarding an elopment

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 July 30, 2024, the Department received a complaint alleging a resident’s toilet is in disrepair.

On August 7 and September 10, 2024, LPA Monter interview Staff S1-S6. All staff interviewed stated if an issue arises regarding a resident’s toilet, the maintenance director will resolve the issue the same day. 3 Out of 6 staff (S1, S2, S6) stated R1’s toilet had an issue because R1 would clog it from using too much toilet paper. S1 stated the moment the staff are informed about an issue with the toilet, then maintenance will fix it by the end of the day.

Page 1 Out of 5.

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 8

Control Number 26-AS-20240730121919

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 22, 2024, LPA Monter interviewed R1. R1 stated he/she doesn’t remember if his/her toilet in his/her bedroom was working.

LPA interviewed R1’s Family Member (FM). FM stated it was possible that R1 was flushing too much toilet paper. FM stated every time an issue regarding the toilet would arise, staff S2 would fix it him/herself.

On September 10, 2024, LPA Monter interviewed Residents R2-R5. 3 Out of 4 residents interviewed (R2, R4, R5) stated their toilet is functional and has not given them any issues. 1 Out of 4 residents interviewed (R3) stated he/she did an issue with his toilet, but it was fixed the same day by the maintenance director.

LPA Monter interviewed facility Maintenance Director (MD). MD stated he/she has gotten a work order for R1’s toilet. MD stated he/she uses a snake “Augger” to unclog it. MD stated when he/she gets notified of an issue with a toilet, he/she will address it the same day as it’s a health and safety issue for the residents. MD stated he/she has several spares in storage that he/she can just replace if the actual toilet is damaged.

On August 7, September 10, 2024, LPA made the following observations. LPA toured the following resident bedrooms: CE1, CE5, CE5, 5, CE9, 9, 20, 21, CE23, CE24, 24, 25, CE25, 29, 30. All resident toilets inspected were observed as clean and functional.

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.

Neglect/lack of supervision resulted in resident eloping.

On July 30, 2024, the Department received a complaint alleging Neglect/lack of supervision resulted in resident eloping. It has been alleged on June 17, 2024, Resident R1 had eloped.

On August 5, 2024, the Department interviewed R1’s family member (FM). FM stated R1 never had a problem with wandering before moving to the facility. FM stated R1 has never wandered when he/she lived with him/her. FM stated wandering was not a concern before moving in. Page 2 Out of 5

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 8

Control Number 26-AS-20240730121919

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, 2024, LPA Monter interviewed ADM and staff S1. ADM and S1 confirmed that on June 17, 2024, R1 had exited the assisted living building (Cedar) around 5am and had walked to the Monterey building. R1 then proceed to throw a flowerpot at the door of the Monterey building. S1 stated R1 then proceeded to knock on room 28’s door. (Independent living.) S1 stated R1 did not enter that resident’s bedroom.

On August 22, 2024, LPA Monter interviewed resident R1. R1 stated regarding June 17, 2024, that he/she does not remember the details. R1 stated he/she went out for a short walk in the morning, but then couldn’t go inside the building. R1 stated he was frustrated that he could not enter the building, so he/she threw something. R1 stated he/she just wanted to walk by him/herself. R1 stated he/she thinks this is the first time this has happened but doesn’t remember.

Based on a review of R1’s Physician Report dated April 21, 2024, R1 has a neurocognitive disorder. The Report also states R1 does not have wandering behavior.

Based on a review of R1’s needs and services plan, dated May 9, 2024, R1 requires 2-hour status checks.

Based on a review of R1’s 2-hour status checks log, R1 was last checked at 4am, on June 17, 2024. R1 was then checked again the same day at 6am.

Based on a review of the facility’s sketch, the Monterey building is part of the facility grounds.

Based on the totality of this investigation, R1 did exit the assisted living building and walk to the Monterey independent living building. Since the Monterey building is part of the facility grounds, R1 did not elope from the facility.

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.

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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 8

Control Number 26-AS-20240730121919

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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Facility did not notify residents responsible party/CCLD regarding an elopement

On July 30, 2024, the Department received a complaint alleging Facility did not notify residents responsible party/CCLD regarding an elopement.

On July 30, 2024, the Department interviewed R1’s family Member (FM). FM stated was he/she was called and informed on June 17, 2024, at 5:30 am R1 left the assisted living building (Cedar) and had thrown a potted plant into the building door.

On August 7 LPA Monter interviewed ADM and staff S1. ADM and S1 confirmed that on June 17, 2024, R1 left the assisted living building (Cedar) around 5am and had walked to the Monterey building. ADM and S1 stated R1 then proceed to throw a flowerpot at the door of the Monterey building then proceeded enter the building and knock on room 28’s door (Independent living.) S1 and ADM stated R1 did not enter that independent living resident’s bedroom. ADM stated he had a discussion with S1 and R1’s family member about R1’s change of condition.

On August 22, 2024, LPA Monter interviewed resident R1. R1 stated on June 17, 2024, he/she went out that morning to take a short walk. R1 stated he/she was finished with the walk, he/she could not re-enter his/her building and became frustrated. R1 stated he/she threw something. R1 stated he/she just wanted to have a walk by him/herself. R1 stated he/she did not have an injury that day and states this is the first time something like this happened.

On October 8, 2024, LPA Monter interviewed staff S1. S1 stated R1's family and physician was notified. S1 stated it was no injury to R1 or other residents because there was no other residents in area at the time of the incident. S1 stated this was a new behavior that was discussed with FM.

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 4 Out of 5.

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: 4 of 8

Control Number 26-AS-20240730121919

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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Facility door alarm is in disrepair

On July 30, 2024, the Department received a complaint alleging the facility door alarm is in disrepair. It has been alleged the door alarm in the assisted living building was in disrepair.

On August 7, and September 10, 2024, LPA Monter interviewed staff S1-S6. 4 Out of 6 staff (S3-S6) interviewed stated the door alarm works and has not had any issue. 2 Out of 6 staff (S1, S2) stated the door alarm had an issue where the door alarm would be keeping ringing during the day, past 6am. S2 stated when the door open, it pages the NOC (Night) shift staff and notifies them that the door had been opened. S1 stated the issue was resolved the same day.

On August 7, and September 10, 2024, LPA Monter interviewed residents R1-R5. R1 stated he/she doesn’t remember if the door alarm was functional. 4 Out of 5 residents (R2-R5) stated the door alarm works and stated there hasn’t been a time when it was not functional.

On September 10, 2024, LPA Monter interviewed the Maintenance Director (MD). MD stated there was an issue with the door alarm. MD stated the if the door opens at 10pm-6am, then the NOC shift’s pager will buzz to notify them that the door had been opened. MD stated the issue was that the door alarm would stay on and keep buzzing even after 6am. MD stated the issue was resolved the same day.

Based on interviews conducted, the door alarm in the assisted living unit was not in disrepair, rather it’s settings were not calibrated correctly.

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 5 Out of 5. 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: 5 of 8

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
07/30/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240730121919

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:	11:40 AM

ALLEGATION(S):

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Facility did not follow eviction procedures
Staff did not follow a licensed physician's order

INVESTIGATION FINDINGS:

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On July 30, 2024, the Department received a complaint alleging the facility did not follow eviction procedures.

On August 7, 2024, LPA Monter interviewed facility ADM and S1. ADM and S1 stated the facility did not evict resident R1. ADM and S1 stated after the incident with the flowerpot on June 17,2024 , they had a discussion with R1’s Family Member (FM) about R1’s change in condition. ADM and S1 stated they informed R1’s FM that 1 on 1 care would be needed after this incident. ADM stated that R1’s FM stated he/she cannot afford the companion. ADM stated that R1’s FM stated he/she would use family members as temporary care givers. ADM stated R1’s FM asked if he/she needed to give a 30 day notice to move out. ADM reiterated that R1 was not evicted and R1’s FM declined to move R1 in memory care.

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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: 6 of 8

Control Number 26-AS-20240730121919

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 22, 2024, LPA Monter interviewed Resident R1’s Family Member. (FM). FM stated after the incident on June 17, 2024, FM stated he/she was informed by the ADM and S1 that R1 would require a higher level of care. FM stated he/she didn’t want R1 in memory care. FM stated he/she was told that R1 would require a 1 on 1. FM stated he/she was told that R1 will need to be moved as quickly as possible. LPA requested FM any documentation from the facility stating R1 was being evicted. FM did not provide LPA with any documentation.

On October 16, 2024, LPA Monter interviewed staff S1.S1 stated he/she and the facility ADM were both there during the conversation with FM. S1 reiterated that the facility did not evict R1. S1 stated that FM told ADM and S1, after the conversation about R1's change of condition, that if he/she needs to give the facility a 30 day notice to vacate.

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 R1 was evicted from the facility.

Staff did not follow a licensed physician's order

On July 30, 2024, the Department received a complaint alleging staff did not follow a licensed physicians order. It has been alleged R1’s medication 1 was not given.

On August 5, 2024, resident R1’s Family Member (FM) stated, R1 was taken to the hospital to see his/her physician. FM stated R1’s physician gave 2 sample medications for R1 to use on May 23, 2024. FM stated he/she brought the medications to the facility and they informed her that they could not give R1 the inhaler since it was a sample even though FM had written a prescription. FM stated he/she administered R1’s medication him/herself, so there would be no delay in R1 receiving the prescription.

On October 2, 2024, LPA Monter interviewed ADM. ADM stated the facility did not administer the medication because the medication did not contain the proper labeling requirements. ADM stated FM did not authorize the pharmacy to fulfill the prescription order.
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: 7 of 8

Control Number 26-AS-20240730121919

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 October 8, 2024, LPA Monter interviewed Staff S1. S1 stated the medication bottle FM brought did not have the state required labeling. S1 stated he/she was going to order the prescription but FM refused. S1 stated, FM only wanted to use the sample due to the cost of the medication. S1 stated FM told him/her that he/she would administer the medication and took the sample medication with him/her.

Based on a review of R1’s needs and Services Plan, dated May 9, 2024, stated R1 receives assistance with self-administration of medications up to 2 times a day.

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 R1 was evicted from the facility.

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: 8 of 8