435200680-11-19-2024-26-AS-KHOS-DBMKLX-20241204070040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200680
Report Date: 11/19/2024
Date Signed: 11/19/2024 11:12:28 AM

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
05/20/2024 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20240520083627

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:	11/19/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Audrey Ann Salvador		TIME COMPLETED:	11:20 PM

ALLEGATION(S):

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Staff did not address resident's change in condition as necessary.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived to the facility unannounced to deliver the complaint investigation findings. LPA met with Administrator, Audrey Ann Salvador.

On 05/20/2024, the Department received the complaint. On 05/22/2024, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1)’s physician’s report, quarterly report through the San Andreas Regional Center, restricted health condition care plan, medication administration record (MAR) for May 2024, progress notes medical records, therapy report, manufacturer’s instructions, and text message exchanges. PAGE 1 OF 3.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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-20240520083627

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: 11/19/2024

NARRATIVE

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It was alleged that the staff did not address resident (R1)’s change in condition starting around 05/11/2024 as necessary as on 05/13/2024, R1’s responsible party had to instruct the staff to check R1’s vitals and send R1 to the hospital after realizing something was wrong. On 05/13/2024, R1’s responsible party received a text from the Administrator regarding R1's condition.

Based on record review, on 05/11/2024, there were no notes regarding a change of condition for R1. On the morning of 05/12/2024, it was stated that R1 was encouraged to shower but R1 refused. R1 claimed that he/she could not breathe and staff asked if R1 would like to use his/her inhalation assistive device. It was noted that R1 called his/her father "claiming" he/she is heavy coughing.

On the morning of 05/13/2024, it noted that R1 was coughing and did not attend day program. R1 stayed in his/her room laying in bed and refused to eat / shower. In the afternoon, R1 refused to eat. It’s noted that R1 kept on insisting that he/she was sick.

The review of the text message exchanges between the Administrator and R1’s responsible party shows that on 05/13/2024 at 3:44PM, the Administrator sent a text to R1’s responsible party stating that R1 did not attend day program and refused to shower for 2 days. The Administrator did not mention that R1 refused to eat and was coughing. R1’s responsible party replied to the Administrator by questioning if R1 had a fever. The Administrator replied but did not answer the question on if R1 had a fever. R1’s responsible party then asked the Administrator for R1’s oxygen level and temperature and begged that the Administrator check for all R1’s symptoms as R1 is unable to articulate his/her source of pain. The Administrator again replied but did not answer the question of R1’s oxygen level, temperature, and symptoms. R1’s responsible party again asked the Administrator for the third time of R1’s oxygen level and temperature, in which then the Administrator sent a picture of R1’s vitals.

Based on record review of R1’s vitals (oxygen, temperature and blood pressure), staff began recording R1’s vitals starting at 6:40PM where it was noted that R1’s oxygen level was at 93 (6:40PM), 85 (8:00PM), 85 (9:30PM), and 94 (8:55PM). PAGE 2 OF 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 26-AS-20240520083627

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: 11/19/2024

NARRATIVE

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R1’s responsible party replied asking the staff to call the advice line for anything under 90 [oxygen level] and stated that R1 may need to go to the emergency room, if R1’s oxygen is truly at 85.

Staff spoke with an advice nurse around 8:55PM – 9:00PM. At 10:00PM, staff called 911 and R1 was transferred to the hospital.

On 05/14/2024, R1 returned from the hospital to the facility at 5:30AM. Based on the medical record, R1 was seen at the emergency room for flu-like symptoms to include a fever, cough, shortness of breath, and body aches.

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 is substantiated.

A deficiency was 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 was provided.

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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 26-AS-20240520083627

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: 11/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/20/2024 Section Cited CCR 85075(b)	1 2 3 4 5 6 7	(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit in writing their procedures in assisting all residents to meet their medical and dental needs. Licensee will submit the written plan to LPA Dolores via email by POC due date of 11/20/2024.
	8 9 10 11 12 13 14	Based on interview, record review and observation the licensee did not comply with the section cited above wherein the licensee did not ensure R1 received necessary medical assistance despite R1 showing symptoms of feeling unwell, until after R1’s responsible party needed to instruct the staff to monitor R1's symptoms and seek medical assistance which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC9099 (FAS) - (06/04)

Page: 4 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
05/20/2024 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20240520083627

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:	11/19/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Audrey Ann Salvador		TIME COMPLETED:	11:20 PM

ALLEGATION(S):

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Staff did not ensure that resident’s medical equipment was maintained in a safe condition
Staff did not inform resident’s responsible party of resident’s change in condition in a timely manner
Staff did not ensure that resident was administered their medication(s) in a timely manner

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 26-AS-20240520083627

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: 11/19/2024

NARRATIVE

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It was alleged that staff did not ensure the resident’s medical equipment was maintained in a safe condition because there was water in the tubing of R1’s inhalation assistive device which caused R1 to have a lung infection. It was also alleged that R1’s inhalation assistive device is supposed to be serviced regularly and was not serviced for 2 years.

On 05/22/2024, 2 staff members were interviewed. Based on interview, S2 states that the Administrator took R1’s inhalation assistive device to the doctor’s office because the device was not working properly. S2 states the water in the tubes of the inhalation assistive device has been happening for a few months and the previous staff was shaking the tubes for the water to come out. S2 states that the staff ordered a new tube "a few months ago". S2 states the current night staff shakes the tubes to get the water out. S2 does not remember if they contacted the facility nurse to inform the nurse about the water inside inhalation assistive device tubes. S2 knew that the water inside the tubes was not okay as the water can go into the lungs. S3 states he/she doesn’t handle R1’s inhalation assistive device but knows the device was leaking. S3 states the device was not leaking before R1 went to the hospital, then when R1 returned, the device was leaking.

The review of records shows that R1’s inhalation assistive device was leaking on 05/12/2024. The device was taken to the doctor’s office by the Administrator for repair on 05/22/2024. Based on interview with the Administrator, R1’s inhalation assistive device was taken to the doctor’s office because it was not functioning as the device was turning off when they turn it on. The Administrator did not know there was water in the tubes of R1’s inhalation assistive device and that the device was leaking.

Based on record review, R1 has a restricted health care plan for the inhalation assistive device which states an action plan for the staff to check that R1’s device is operating correctly based on the device operations manual instructions.

The review of the manufacturers instructions, states a caution section to regularly check the device’s tub, air tubing, and air filter for any damage and to replace the tub if it is leaking. The troubleshooting section states instructions to decrease or increase the settings for when there are droplets of water in the nose, in the mask, and air tubing. PAGE 2 OF 4.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 26-AS-20240520083627

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: 11/19/2024

NARRATIVE

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The servicing instructions writes, “it is recommended for the device to be inspected and serviced if there is any sign of wear or concern with the device function. Otherwise, service and inspection of the product generally should not be required during their design life”.

Based on review of R1’s medical records, although it is noted that R1 was diagnosed with a lung infection there was no indication that R1’s lung infection was caused by the water in the tubes of the inhalation assistive device.

It was alleged that staff did not inform R1’s responsible party of R1’s change of condition (starting on 05/11/2024) in a timely manner, as R1’s responsible party received a text from the Administrator on 05/13/2024 regarding R1's condition.

Based on record review, on 05/11/2024, there were no notes regarding a change of condition for R1. On 05/12/2024, R1 refused to shower and claimed that he/she could not breathe. On 05/13/2024, the Administrator contacted R1’s responsible party via text stating that R1 did not attend day program and refused to shower for 2 days.

Based on interview with the Administrator, the staff knew that R1 was not feeling well and were monitoring his/her symptoms and physical appearance. Based on record review, on 05/12/2024 R1 spoke with his/her parent claiming he/she is heavy coughing. The Administrator states to have sent a text to R1’s responsible party on 05/13/2024 regarding R1’s condition.

It was alleged that on 05/14/2024, staff did not ensure R1 was administered their medications in a timely manner after being discharged from the hospital and returning to the facility around 6AM. It was stated that R1’s prescription was written out around 4:45AM and R1 was not given his/her prescribed medication until about 8PM.

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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 26-AS-20240520083627

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: 11/19/2024

NARRATIVE

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Based on interview with the Administrator, on 05/14/2024 the Administrator was on the way to pick up R1’s medications in San Jose when Licensing arrived to the facility.
The Administrator instructed another staff to pick up R1’s medications, instead, as the Administrator needed to meet with Licensing.

After the Licensing visit, the Administrator drove to San Jose and back to Gilroy to drop off R1’s medications.

The review of records shows that R1 was prescribed 2 new medications. Medication #1’s instruction stated to take 2 tablets by mouth daily for 1 day, then 1 tablet daily for 6 days. Medication #2’s instruction stated to take 1 tablet by mouth 2 times a day with meals for 7 days. Both medications did not include instructions to take the medication at a specific time or within a specific time-frame. Based on record review, R1 was administered both medications the night of 05/14/2024.

The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

A case management visit was conducted due to violations observed during this investigation. See LIC809 for 11/19/2024.

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

PAGE 4 OF 4.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 8