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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200680
Report Date: 07/23/2024
Date Signed: 07/23/2024 05:23:24 PM

Substantiated


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
05/06/2024 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20240506090411
FACILITY NAME:MONTE BELLO ADULT CARE HOMEFACILITY NUMBER:
435200680
ADMINISTRATOR:DULCE ROSE CERAFACILITY TYPE:
735
ADDRESS:998 A-B MONTE BELLO DRTELEPHONE:
(408) 847-9999
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:6CENSUS: 6DATE:
07/23/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Audrey Ann SalvadorTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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Facility staff do not meet training requirements
Facility staff do not follow the resident's needs and services plan
Facility did not report a resident's missed medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegations. LPA met with Administrator, Audrey Ann Salvador.

On 05/06/2024, the Department received the complaint. On 05/14/2024, the initial complaint investigation was conducted.

The following documents were obtained for this investigation to include the resident roster, staff schedule from April - May 2024, 4 staff members training records, Administrator Certificate, and resident (R1)’s physician's report, IPP, appraisal/needs and services plan, progress notes from April - May 2024, MAR from April - May 2024, and restricted health condition care plan. PAGE 1 OF 3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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 6
Control Number 26-AS-20240506090411
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: MONTE BELLO ADULT CARE HOME
FACILITY NUMBER: 435200680
VISIT DATE: 07/23/2024
NARRATIVE
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Facility staff do not meet training requirements and Facility staff do not follow the resident’s needs and services plan

On 05/06/2024, it was alleged that the new facility staff are not trained on resident (R1)’s needs and services plan therefore are not following the resident’s needs and services plan.

4 staff members were interviewed. Based on interview, the new staff members provided care to R1. It was also stated that the new staff provided 1:1 care to R1.

Based on interview, facility staff contacted the facility’s nurse consultant to provide the new staff members training on R1’s restricted health condition care plan, however, the nurse consultant was unable to provide training at the time due to medical reasons. The Administrator did not contact another nurse consultant to provide training for the new staff on R1’s restricted health condition care plan prior to providing care to R1.

During the course of this investigation, staff training records were obtained. Based on record review, the new staff that were hired are not provided training on R1’s restricted health condition care plan resulting in the staff not following R1's needs and services plan. The review of records shows the last training on R1’s restricted health condition care plan was last completed on 01/12/2022, which does not include the new staff hired in the beginning of 2024.

Facility did not report a resident’s missed medication

On 05/06/2024, it was alleged that the facility did not properly report a resident (R1)’s missed medication to R1’s responsible party.

PAGE 2 OF 3.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20240506090411
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: MONTE BELLO ADULT CARE HOME
FACILITY NUMBER: 435200680
VISIT DATE: 07/23/2024
NARRATIVE
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On 05/14/2024, LPA Dolores conducted an unannounced visit and reviewed 3 residents centrally stored medications. LPA observed medication errors for 2 out of 3 residents. Based on record review and observation, R1 missed 2 medications in the evening of 04/25/2024. On 04/06/2024, R2 missed 1 medication.

Based on staff interview, S1 was unable to provide a reason to why R1 missed the medications. S1 confirmed that S2 did miss a medication in April 2024. It was stated that the staff who missed the medication was new. After the incident, the staff was provided a verbal warning and re-training on medications.

Based on interview, an incident report was not sent to the Department nor were the responsible parties notified of the missed medication. It was stated that the Administrator was new to the facility and did not know the missed medication needed to be reported.

LPA reviewed the facility’s incident reports that was sent to the Department. LPA Dolores did not locate any incident reports in April 2024 regarding missed medications for R1 and R2. The Administrator was unable to provide proof that R1 and R2’s responsible parties were notified of the missed medications.

The Department has investigated the above allegation. Based on interview, record review, and observation the preponderance of evidence standard has been met, therefore, the above allegations are substantiated.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC9099-D.

This report was reviewed with Administrator, Audrey Ann Salvador and a copy of the report and appeal rights were provided.

PAGE 3 OF 3.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20240506090411
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: MONTE BELLO ADULT CARE HOME
FACILITY NUMBER: 435200680
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2024
Section Cited
CCR
80092.1(g)
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(g) All new facility staff who will participate in meeting the client’s specialized care needs shall complete the training prior to providing services to the client. This requirement is not met as evidenced by:
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Licensee will review the section cited. Licensee will submit a statement of understanding of the section cited to LPA Dolores via email by POC due date.
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Based on interview, record review and observation the licensee did not ensure new facility staff were provided training on R1's restricted health condition care plan prior to providing care to R1 which poses an immediate health, safety, and personal rights risk to persons in care.
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Type B
07/30/2024
Section Cited
CCR
80061(f)
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(f) The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any. This requirement is not met as evidenced by:
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Licensee will review section 80061. Licensee will submit a statement of understanding of the section cited to LPA Dolores via email by POC due date.
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Based on interview, record review, and observation the licensee did not ensure to inform R1 and R2’s authorized representative regarding the missed medications which poses a potential health, safety, and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20240506090411
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: MONTE BELLO ADULT CARE HOME
FACILITY NUMBER: 435200680
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2024
Section Cited
CCR
80061(b)(1)(E)
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(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement is not met as evidenced by:
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Licensee will review section 80061. Licensee will submit a statement of understanding of the section cited to LPA Dolores via email by POC due date.
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Based on interview, record review, and observation the licensee did not ensure to report to the Department regarding R1 and R2’s missed medication which poses an potential health, safety, and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6