435200930-2-23-2023-26-AS-KHOS-CQCKGD-20230328075321

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200930
Report Date: 02/23/2023
Date Signed: 02/23/2023 05:13:06 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
01/18/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20230118135211

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:	01:30 PM
MET WITH:	Valerie Alves		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility fails to clean resident’s bodily waste
Facility is not administering medications according to doctor’s prescriptions

INVESTIGATION FINDINGS:

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

On 01/18/2023, the Department received a compliant with the above allegations and conducted an initial complaint visit on 01/25/2023.

During visit on 01/25/2023, LPA Marrufo observed 7 resident living units, including resident R1’s living unit, in the facility Memory Care Unit. LPA Marrufo observed that 7 out of 7 observed resident rooms did not have any signs of uncleaned bodily waste.

See LIC9099-C for more information. 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: 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 2

Control Number 26-AS-20230118135211

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 7 Memory Care staff. All 7 out of 7 interviewed staff stated that staff usually clean bodily waste in a resident’s room in around 5 minutes. They all stated during interview that although housekeepers are not on duty from 5PM to 7 AM, CNAs and nurses at the facility during those hours will clean any bodily waste in a resident’s room. The staff stated that there is an emergency cleaning kit available to staff when the housekeepers are not available. LPA Marrufo observed the emergency cleaning kit near the kitchenette in the Memory Care Unit. The emergency cleaning kit contained cleaning sprays, a cleaning brush, and a cleaning bucket.

LPA Marrufo interviewed R1’s Durable Power of Attorney (DPOA) #1, #2, and #3. DPOA #2 stated that R1 has a behavior of leaving bodily waste in R1’s living unit. DPOA #1 stated that there R1 has a private duty care aid who would be available to clean up any bodily waste in R1’s living unit. DPOA #2 stated there was an incident in which R1 had left bodily waste in R1’s living unit, and DPOA #3 wanted staff to clean the bodily waste immediately. However, the facility staff were serving lunch at the time and told DPOA #3 that they would clean the bodily waste after lunch because the staff did not want to handle bodily waste while serving lunch.

LPA Marrufo interview staff S1, who also stated that there was an incident when staff did not immediately clean R1’s bodily waste in R1’s living unit because lunch was being served at that time and staff did not want to handle bodily waste while serving lunch to residents.

During interview, DPOA #3 stated that there was bodily waste in R1’s living unit and no staff came to clean up the bodily waste.

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.

Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation 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 the report was 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: 2 of 2