435200786-6-4-2020-26-AS-GNWR-BRQM76-20200721092101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200786
Report Date: 06/02/2020
Date Signed: 06/04/2020 02:29:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/14/2020 and conducted by Evaluator Maria Kamara

COMPLAINT CONTROL NUMBER: 26-AS-20200514130335

FACILITY NAME:	MERTZ CARE HOME III		FACILITY NUMBER:	435200786
ADMINISTRATOR:	JIMENEZ, Y. ROGELINE		FACILITY TYPE:	740
ADDRESS:	3928 THAINWOOD WAY		TELEPHONE:	(408) 532-7020
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY:	6	CENSUS: 5	DATE:	06/02/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Elvira Mertz and Rogeline Jimenez		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff hit resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 6/2/2020, Licensing Program Analyst (LPA) Maria Kamara conducted an unannounced subsequent complaint investigation via tele-conference call with the facility, spoke with both Licensee Elvira Mertz and Administrator Rogeline Jimenez who were informed of the reason for the call which was to deliver finding on the above allegation. LPA Maria informed Licensee Elvira and Administrator Rogeline that due to the current COVID-19 "shelter in place" the Department is currently conducting tele-conference call in the place of an onsite complaint investigation.

On 5/18/2020 at 8:10AM, during a complaint investigation visit at the facility, LPA Maria observed five residents at the facility. LPA did a wellness check on the residents. There was no injury or bruise observed on (R1) via Facetime video call.

See continuation Pg.2 of LIC9099.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Maria Kamara	TELEPHONE: (650) 388-2295
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2020

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 3

Control Number 26-AS-20200514130335

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MERTZ CARE HOME III	FACILITY NUMBER: 435200786
	VISIT DATE: 06/02/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Pg.2

On 5/18/2020 at 8:17AM, LPA interviewed R1 and was able to respond by stating his name correctly. R1 stated R1 is doing fine and is happy at the facility. R1 denied being hit by staff or any physical abuse by staff at the facility. R1 stated, that “staff are good and nice to me”. R1 stated that he loves the staff.

On 5/18/2020, at 8:25AM, three out of five residents (R1-R3) were interviewed via tele-conference Facetime video call. Three out of five residents (R1-R3) stated to LPA that they were doing fine and have no problems at the facility. Three out of five residents (R1-R3) denied being hit by staff or any physical abuse at the facility. LPA attempted to interview (R4) resident is non-verbal. One out of five resident (R5) was not available for interview.

On 5/18/2020 at 9:05AM, five staffs, (S1-S5) were interviewed via tele-conference Facetime video call. Staffs (S1-S5) stated that staff follows facility protocols on residents’ personal rights and abuse policy. Staffs (S1-S5) stated that staff have not witnessed other staff hit R1 or any resident at the facility. Staff (S1-S2) denied pointing a stick or throwing any object or sandwich at (R1) during Zumba Virtual day program class on 5/13/2020.

On 5/18/2020 at 9:55AM, three residents and three staff’s records were reviewed with the Administrator. Copies of documents pertaining to the complaint were obtained.

On 5/19/2020 at 2:23PM, LPA Maria interviewed R1's day program staff and stated that during a Zumba Virtual Day Program class, staff observed what looks like staff hit resident on the head and saw what looks like a stick pointed at R1. Day program staff also captured on a video taken from personal cell phone what appeared to be a sandwich thrown at R1.

On 5/22/2020 at 11:27AM, LPA Maria interviewed Local Long Term Care Ombudsman (LTCO) and stated that she was unable to interview (S1) as staff was suspended and is unavailable at the facility. Stated (R1) was interviewed and was unable to respond to questions being asked in regards to being hit by staff.

See continuation Pg.3 of LIC9099C

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Maria Kamara	TELEPHONE: (650) 388-2295
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20200514130335

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MERTZ CARE HOME III	FACILITY NUMBER: 435200786
	VISIT DATE: 06/02/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Per review of San Jose Police Department report dated 5/14/2020, indicated that alleged elder abuse are unconfirmed.

Based on available information gathered, LPA's inspection, observations, interviews with staffs, residents and agency staff, San Jose Police Department report and review of supporting documents obtained during the cause of the investigation, the preponderance of evidence standard has been met therefore the allegation “Facility staff hit resident” is UNSUBSTANTIATED. Meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited as a result of this complaint investigation. Exit interview is conducted with Licensee Elvira Mertz and Administrator Rogeline Jimenez.

LPA Maria informed Licensee Elvira Mertz and Administrator Rogeline Jimenez that a copy of the signed LIC9099 by LPA Maria will be emailed to the facility at: rogeline@mchinc.net for signature and returned to LPA Maria. The original of the document to be mailed to CCL office.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Maria Kamara	TELEPHONE: (650) 388-2295
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3