435201557-9-24-2024-26-AS-RMAO-D9VUMM-20241009154233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201557
Report Date: 09/24/2024
Date Signed: 09/24/2024 12:50:54 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
02/06/2024 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20240206092923

FACILITY NAME:	PRUNERIDGE RESIDENTIAL CARE HOME		FACILITY NUMBER:	435201557
ADMINISTRATOR:	CORTES, LEILANI		FACILITY TYPE:	740
ADDRESS:	3030 PRUNERIDGE AVENUE		TELEPHONE:	(408) 247-2771
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	6	CENSUS: 6	DATE:	09/24/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Lead Caregiver, Rose (Rosalia) Calungcagin		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff are not ensuring resident's oral hygiene needs are met
Staff are not ensuring resident is repositioned every two hours

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Simi Rai and Marcela Yanez conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Lead Caregiver, Rose (Rosalia) Calungcagin and stated the purpose of today’s visit.

On 2/6/2024, the Department received a complaint with the above allegations. It was alleged that R1 was admitted to the hospital on 2/3/2024 and resident had not received any oral care and resident had a pressure injury stage 1 from not being repositioned every 2 hours. On 2/15/2024, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

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-20240206092923

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: PRUNERIDGE RESIDENTIAL CARE HOME	FACILITY NUMBER: 435201557
	VISIT DATE: 09/24/2024

NARRATIVE

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Page 2 of 3.

Staff are not ensuring resident’s oral hygiene needs are met.

On 2/15/2024, LPA Rai interviewed 3 staff, including staff (S1) who was the primary caregiver for R1. One staff (S3) did not provide direct care to R1. Two out of two staff stated the facility staff provided oral care to resident every morning and R1 did not have any issues, pain or redness related to R1’s mouth, gums, or jaws. Two out of two staff stated R1’s responsible party would make arrangements for dentist appointments.

Based on review of R1’s Physician’s Report dated 4/12/2023, R1 does not wear dentures and does not have special diet. R1 is able to feed himself/herself. R1 is not able to groom himself/herself. Based on review of R1’s Progress Note on 2/1/2023, staff did not note any issues related to oral care or resident refusing oral care.

Staff are not ensuring resident is repositioned every two hours.

On 2/15/2024, LPA Rai interviewed 3 staff, including staff (S1) who was the primary caregiver for R1. One staff (S3) did not have direct care experience with R1. Two out of two staff stated R1 was observed in the morning of 2/3/2024 before going to the hospital and R1 did not have any bruising or wounds on the buttocks.

Two out of two staff stated R1 was able to reposition himself/herself and needed assistance to transfer. Two out of two staff stated the facility staff would assist R1 in sitting in the dining room or living room. S1 stated R1 would be repositioned every two hours or even sooner depending on if R1 wanted to go to dining room or living room.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240206092923

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: PRUNERIDGE RESIDENTIAL CARE HOME	FACILITY NUMBER: 435201557
	VISIT DATE: 09/24/2024

NARRATIVE

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Page 3 of 3.

Based on review of R1’s Physician’s Report dated 4/12/2023, R1 does not require continuous bed care. R1 does not have a history of skin condition or breakdown.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Lead Caregiver Rosalia (Rose) Calungcagin and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3