435200930-12-5-2024-26-AS-ACON-DCCPN6-20241227102723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200930
Report Date: 12/05/2024
Date Signed: 12/05/2024 04:03:45 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
10/22/2024 and conducted by Evaluator Kiran Jain

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20241022110947

FACILITY NAME:	VI AT PALO ALTO		FACILITY NUMBER:	435200930
ADMINISTRATOR:	JOHN KOSELAK		FACILITY TYPE:	741
ADDRESS:	620 SAND HILL ROAD		TELEPHONE:	(650) 853-5000
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94304
CAPACITY:	876	CENSUS: 570	DATE:	12/05/2024
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Andrea Fadem		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff restrained resident.
Staff are not following reporting requirements.

INVESTIGATION FINDINGS:

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On 12/05/2024, at 3:15 PM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a complaint investigation visit. LPA met with Director of Nursing, Andrea Fadem and Neda Armanfar, Director of Assisted Living, and disclosed the purpose of the visit.

Regarding the allegations that Staff restrained resident, the reporting Party (RP) stated "LVN, Jean reported that on or around 9/22/2024, she was new to her role and was training under Jing, who is a nurse. RP stated that Jean and Jing went to client's room to give client a suppository in the client's rectum because client was experiencing constipation. Per Jean, client was being uncooperative, so Jing called In five (5) Certified Nurse Assistants (CNAs) to restrain the client, In order for Jing to administer the suppository in the client's rectum. Afterwards, client was released. It is unknown if the client sustained any injuries. Jean said she called the Ombudsman after the incident, but she did not hear back. Per Jean, it was unethical and against Vi's company policy to treat a patient in this manner.".

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20241022110947

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: 12/05/2024

NARRATIVE

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Based on the staff (S1, S2, S3, S4, and S6) interviews conducted on 10/30/2024 and 12/02/2024 with (5) staff members, Resident (R1) didn’t have a bowel movement for a few days. Doctors ordered to give him a suppository. R1 asked about the suppository and ok’d to be given the suppository. PDA (Private duty aid) was present with the R1. There was no restraint used. R1 was cooperative. The nurse (S3) asked for a CNA (S4) assigned to help. Staff got R1 on his side. R1 didn’t complain. Staff lifted R1’s leg and the suppository was given. R1 was advised that they should stay in bed for an hour or so. S3 and S4 don’t remember the nurse (RP2) alleging the incident was present in the room. RP2 was going under orientation and was a new employee there.

Based on the private caregiver (PDA) interview conducted on 12/02/2024, PDA stated that S3 and S4 asked R1 if it was ok to put the suppository since R1 didn’t have bowel movements for almost 3-4 days. R1 asked what this was for and what was being done. S3 explained what they were going to do and explained they wanted to put this on their back. R1 said OK, then S3 put the suppository. S3 asked the resident to turn to the side facing the window. It helped R1 with the bowel movement and relieved the constipation. R1 was cooperative. Only S3 and S4 were present and RP2 was not in the room when the suppository was administered. R1 didn’t complain of any pain or discomfort during the procedure. Nothing unusual happened. If the abuse was there, PDA would have told their agency and R1’s family.

Based on the R1’s family member (FM1 and FM2) interview conducted on 11/13/2024, FM2 stated that they have a 24x7 thread with their caregivers. They weren’t aware that this happened. Staff would know if any boundaries were pushed. If this incident happened, FM2 would be 100% certain that they would be pressing charges. PDA staff is very cautious. They all understood if anything became a problem, they would be there within 15 minutes. They will call us, and they know that. Violation cannot happen. Nurses would have informed us. They didn’t even allow sleep medicine that was not allowed by the doctor.

Regarding the allegations that Staff are not following reporting requirements, Reporting Party (RP) stated that Jean was told by Jing not to document the restraint.

Based on the staff (S1, S2, S3, S4, and S6) interviews conducted on 10/30/2024 and 12/02/2024 with (5) staff members, detailed notes are documented in R1’s progress notes, and suppository and medications administered are documented in Medical Administration Record (MAR).

Continued on LIC9099-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20241022110947

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: 12/05/2024

NARRATIVE

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Based on the R1’s family member (FM1 and FM2) interview conducted on 11/13/2024, FM2 stated that the facility documents everything even if any fall happens.

Based on the records review conducted on 11/13/2024, the facility documented the suppository administered in the Medical Administration Record (MAR), given at 8:06 PM on 09/22/2024 for constipation. The Progress Notes indicated that R1 was alert and verbally responsive. All due meds were given and tolerated well by R1. PDA was in the room on standby to assist with need.

Based on observations, interviews conducted with staff members, a private caregiver, and family members, and records reviewed, the department has determined that 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 were cited under the California Code of Regulations, Title 22.

An exit interview was conducted. A copy of this report was discussed and left with the Neda Armanfar, Director of Assisted Living, whose signature on this form confirms receipt of this report.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

LIC9099 (FAS) - (06/04)

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