435200680-5-22-2025-26-AS-MPAA-DHJ8XG-20250610225420

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200680
Report Date: 05/22/2025
Date Signed: 05/22/2025 03:04:43 PM

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
09/20/2024 and conducted by Evaluator Christine Kabariti

COMPLAINT CONTROL NUMBER: 26-AS-20240920103156

FACILITY NAME:	MONTE BELLO ADULT CARE HOME		FACILITY NUMBER:	435200680
ADMINISTRATOR:	AUDREY ANN SALVADOR		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:	05/22/2025
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Audrey Ann Salvador		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff did not administer resident's eye drops as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived unannounced to deliver the finding of the above allegation. LPA met with Administrator, Audrey Ann Salvador.

On 09/18/2024, the Department received the complaint. On 09/24/2024, the initial complaint investigation was conducted. The following documents were obtained to include resident (R1)’s physician’s report, appraisal/needs and services plan, IPP, medication records, medical records, and incident reports.

It was alleged that facility staff did not administer resident’s eye drops as prescribed as R1’s eye drops were being administered at the same time. R1 is diagnosed with an eye condition and it was alleged that the improper administration of the resident’s eye drops caused an increase in R1’s eye pressure. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

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 2

Control Number 26-AS-20240920103156

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: 05/22/2025

NARRATIVE

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Based on record review, R1 is prescribed 2 different eye drops. Medication #1 (M1) instructions is to instill one drop four times daily into both eyes. The facility was administering R1’s the eye-drops at 7AM, 2PM, 5PM, and 7PM.

Medication #2 (M2) instruction is to instill one drop into both eyes at bedtime. Based on record review, the facility was administering R1 the eye drops also at 7PM.

Based on M2’s medication instructions / drug facts, it stated that the drug should be administered at least 5 minutes apart if it is being used together with other eye drops.

A witness (W1) was interviewed. Based on W1 interview, it was stated that because the staff was administering medication #1 (M1) and medication #2 (M2) at the same time, M2 was not able to take into effect because it was being diluted by M1. W1 states this had caused increased pressure in R1’s eyes. It was stated that after the doctor had discontinued M1 for night use and prescribed only M2 for bedtime, R1’s eye pressure has decreased.

6 staff members were interviewed. Based on staff interview, it was stated that the staff knew to ensure R1’s eye drops were administered at separate times or else M2 would not take into effect. It was stated that staff administered M2 before bedtime. It was stated that even though the medication administration record indicates a time of 7PM, the staff can give the medication within that same hour, in which staff were administering both M1 and M2 at separate times and not at the same time.

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. A case management visit was conducted due to a violation observed during the investigation, see LIC809 for 05/22/2025. This report was reviewed with Administrator, Audrey Ann Salvador and a copy of the report was provided.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

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