435200680-9-24-2024-26-AS-KHOS-D9MGVZ-20241001054133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200680
Report Date: 09/24/2024
Date Signed: 09/24/2024 10:41:17 AM

Unsubstantiated

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 HOME		FACILITY NUMBER:	435200680
ADMINISTRATOR:	DULCE ROSE CERA		FACILITY TYPE:	735
ADDRESS:	998 A-B MONTE BELLO DR		TELEPHONE:	(408) 847-9999
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	6	CENSUS: 6	DATE:	09/24/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Anelise Teodoro		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Facility does not have sufficient staff to meet the needs of residents

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 Designated Administrator, Anelise Teodoro.

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, staff (S1 - S4)'s training records from 2023 - 2024, 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, and staff time cards. PAGE 1 OF 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

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

LIC9099 (FAS) - (06/04)

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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: 09/24/2024

NARRATIVE

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It was alleged that the facility does not have sufficient staff to meet the needs of the residents due a staffing ratio observation on 05/04/2024. On 05/04/2024, a witnessed observed the facility only had 2 staff members to 6 residents around 2:00PM, while R1 required a 1:1 staff.

Based on interview with the Administrator, R1’s 1:1 staff is not included in the direct care staffing ratio. The review of the direct care staff schedule indicates that 3 staff were expected to work from 8:00am – 7:00pm, making R1’s 1:1 staff the 4th person.

The review of the facility staff time cards shows from 6:00am – 2:00pm = 2 staff were working; 2:00pm – 3:30pm = 3 staff were working; 3:30pm – 4:00pm = 2 staff were working; 4:00pm – 7:00pm = 3 staff were working.

Based on record review and observation, the facility had the expected 3 direct care staff from 2:00pm – 3:30pm and 4:00pm – 7:00pm, leaving only 2 direct care staff from 6:00am – 2:00pm and from 3:30pm – 4:00pm.

The review of R1’s 1:1 staffing schedule indicates that the ADM was assigned as R1’s 1:1 staff from 6:00am – 2:00pm and staff (S2) was assigned as R1’s 1:1 staff from 2:00pm – 10:00pm.

Based on interview with the ADM, ADM and S2 are salary employees and are not required to fill out a timecard for each shift. ADM states to be working at the facility as R1’s 1:1 staff on 05/04/2024. LPA attempted to interview S2 but was unsuccessful.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Designated Administrator, Anelise Teodoro and a copy of the report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC9099 (FAS) - (06/04)

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