435200930-2-23-2023-26-AS-KHOS-CQYLKV-20230417085012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200930
Report Date: 02/23/2023
Date Signed: 02/23/2023 05:15:00 PM

Unfounded

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
11/14/2022 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20221114101722

FACILITY NAME:	VI AT PALO ALTO		FACILITY NUMBER:	435200930
ADMINISTRATOR:	STEVE A. BRUDNICK		FACILITY TYPE:	741
ADDRESS:	620 SAND HILL ROAD		TELEPHONE:	(650) 853-5000
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94304
CAPACITY:	876	CENSUS: 598	DATE:	02/23/2023
		UNANNOUNCED	TIME BEGAN:	01:38 PM
MET WITH:			TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility has not created a care plan for resident.
Facility has not created an admission agreement for resident.
Facility staff is not assisting resident with feeding.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Complaint Investigation Visit and met with Valerie Alves.

On 11/14/2022, the Department received a compliant with the above allegations and conducted an initial complaint visit on 11/17/2022.

LPA Marrufo obtained a copy of resident R1’s Service Plan for Assisted Living/Memory Services, which states R1 was observed on 10/06/2022. The document provides the plans for R1’s Activities of Daily Living, Medication Administration, and Behavioral Issues.

See LIC9099-C for more information. Page 1 of 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

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-20221114101722

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: VI AT PALO ALTO	FACILITY NUMBER: 435200930
	VISIT DATE: 02/23/2023

NARRATIVE

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LPA Marrufo obtained a copy of R1’s Continuing Care Residency Contract, which was signed by R1 on 11/11/2011.

R1’s Service Plan states that R1 is independent of eating. It states, “Resident eats by herself, but Vi staff will serve plates.” It states R1 has no special dietary needs/diet/supplements.

During visit on 11/17/2022, LPA Marrufo observed R1 during meal service. LPA Marrufo observed staff serve R1 a meal. LPA Marrufo did not observe staff assisting R1 with feeding. LPA Marrufo observed R1 eating shrimp, salmon, chopped fruits, and drinking orange juice. LPA Marrufo observed R1 use a spoon to eat fruits and mashed potatoes without assistance.

LPA Marrufo interviewed 6 staff. 6 out of 6 interviewed staff stated R1 feeds himself/herself during meals.

This agency has investigated the complaint allegations listed. Based on interviews, review of records, and observations, the CCLD has found that the complaint allegations are unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

This report was reviewed with Valerie Alves and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
11/14/2022 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20221114101722

FACILITY NAME:	VI AT PALO ALTO		FACILITY NUMBER:	435200930
ADMINISTRATOR:	STEVE A. BRUDNICK		FACILITY TYPE:	741
ADDRESS:	620 SAND HILL ROAD		TELEPHONE:	(650) 853-5000
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94304
CAPACITY:	876	CENSUS: 598	DATE:	02/23/2023
		UNANNOUNCED	TIME BEGAN:	01:38 PM
MET WITH:			TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility is not administering medications and treatments to resident.
Facility staff is not allowing resident to refuse medications.
Facility is not allowing resident to choose own home care companion.

INVESTIGATION FINDINGS:

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*Amended on 03/27/2023 to add details about allegation of administering medications and treatments to resident* Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Complaint Investigation Visit and met with Valerie Alves.On 11/14/2022, the Department received a compliant with the above allegations and conducted an initial complaint visit on 11/17/2022. LPA Marrufo reviewed R1’s medications, Medication Administration Record (MAR) and Physicians Order Report, which lists R1’s prescribed medications. After reviewing the medications and MAR, LPA did not find any medications that were not administered according to prescription orders. LPA Marrufo obtained copies of R1’s Medication Administration Record (MAR). R1’s MAR indicates that R1 refused medication from 11/01-7/2022, 11/09-15/2022, and 01/05/2023. LPA Marrufo interviewed R1 Durable Power of Attorney (DPOA) #1 and DPOA #2. Both stated that they have not observed a time when the facility did not allow R1 to refuse medication. LPA Marrufo interviewed R1’s DPOA #3 who stated to be present when R1 stated “no thank you” to staff when being offered two medications, but staff provided the medications to R1 anyway. DPOA #3 was not able to provide a date or time of the incident. See LIC9099-C. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20221114101722

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: VI AT PALO ALTO	FACILITY NUMBER: 435200930
	VISIT DATE: 02/23/2023

NARRATIVE

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LPA Marrufo interviewed 6 staff. 2 out of 6 staff stated the staff allow R1 to refuse medications. 4 out of 6 staff said they did not know if staff allow R1 to refuse medications.

LPA Marrufo interviewed 4 Memory Care residents, including R1, and 3 Assisted Living Residents. All of the interviewed residents stated they have not had a time when they were not allowed to refuse medications.
Section 4.6(iv) of R1’s Admission Agreement states that all providers of home health care and private duty aide services must be employed by a licensed agency.

DPOA #1 and DPOA #2 stated that the facility has not prevented them from choosing a home care companion for R1. DPOA #1 and DPOA #2 have both stated that DPOA #3 has been hired as R1’s private duty aid. LPA interviewed 6 staff. 6 out of 6 interviewed staff stated R1 has a home care companion.

Staff S1 and S2 both stated during interview that the facility only allows residents to hire private duty care givers from agencies, but facility would not intervene in residents hiring their own family members as care givers, so long as the family members still adhered to the visitation policy and visitation hours.

During interview, DPOA #3 stated S2 communicated to DPOA #3 that DPOA #3 would not be allowed to be a private care giver for R1 because DPOA #3 is related to R1.

During interview, S2 stated to have not communicated to DPOA #3 that DPOA #3 could not be a private care giver for R1 due to being related to R1. S2 stated to have communicated to DPOA #3 that all private care givers must be hired through an agency and any family member being privately hired by a resident to provide care must still abide by the facility visitation policy.

Based on information from interviews conducted with staff, and records reviewed, and observations, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. This report was reviewed with Valerie Alves and a copy of this report provided. Page 2 of 2. END REPORT.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4