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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200680
Report Date: 06/19/2025
Date Signed: 06/19/2025 04:00:56 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
09/18/2024 and conducted by Evaluator Christine Kabariti
COMPLAINT CONTROL NUMBER: 26-AS-20240918165131
FACILITY NAME:MONTE BELLO ADULT CARE HOMEFACILITY NUMBER:
435200680
ADMINISTRATOR:AUDREY ANN SALVADORFACILITY TYPE:
735
ADDRESS:998 A-B MONTE BELLO DRTELEPHONE:
(408) 847-9999
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:6CENSUS: 6DATE:
06/19/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Audrey Ann SalvadorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility did not provide proper care to meet the resident's needs resulting in a blood clot
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived unannounced to deliver the finding of the above allegations. 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 the facility did not provide proper care to meet resident (R1)’s needs resulting in a blood clot, as it was alleged that the facility did not have R1 stand and walk periodically to promote blood circulation to his/her leg. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
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 4
Control Number 26-AS-20240918165131
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: 06/19/2025
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On 09/12/2024, R1's medical records from the hospital visit notes that testing was completed, which did not show any blood clots. On 09/17/2024, during a follow-up visit with R1's doctor noted under the “history of present illness” section that R1 is here for a follow-up on a blood clot that was provoked by inactivity, sitting at the computer many hours during the day for days at a time.

Based on staff interview, 4 out of 4 staff members states that R1 participates in activities at the facility daily. Staff stated that R1 has the same routine every day after day program to include a variety of activities like dancing and walking around the facility daily. 4 out of 4 staff denied allowing R1 to watch movies all day and his/her laptop. Staff stated that prior to R1 going to the hospital, R1’s routine did not change. Staff stated that R1 continued to participate in activities daily to include exercise.

A witness (W2) was interviewed. Based on witness interview, it was stated that he/she knew how the facility staff worked and believed the staff would allow R1 to sit down all day to color and watch movies when he/she was not working. W2 stated that whenever he/she was working, he/she would need to remind the staff to play music for R1 so R1 can exercise.

The review of R1’s care plan states that R1 should maintain a walking regimen.

Based on interview with R1, it was stated he/she participates in activities at the facility to include exercise twice a day.

Based on review of R1’s medical records, it’s indicated that R1 has history of obesity and other health conditions which require the use of certain medications that may increase the risk factors of developing a blood clot, if the resident was active as staff and resident claims.

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 Regulation, Title 22. 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: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4