435201557-9-13-2021-26-AS-RMAO-C79RYE-20210927132613

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201557
Report Date: 09/13/2021
Date Signed: 09/13/2021 02:34:38 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
02/19/2021 and conducted by Evaluator Joanne Roadilla

COMPLAINT CONTROL NUMBER: 26-AS-20210219094337

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: 5	DATE:	09/13/2021
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Rosalia Calungcagin		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident fell while in care.
Licensee did not provide medical assistance in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Complaint Investigation to deliver the investigation findings on the above allegations. LPA spoke to Licensee/Administrator Leilani Cortes to discuss the purpose of the visit.

On 02/19/21, the department received a complaint with the above allegations. On 02/26/21, LPA conducted an initial 10-day investigation tele-visit. LPA interviewed licensee, two regular staff (S1-S2) and two temporary staff (S3-S4) at the facility. LPA also requested for residents’ records.

Continued on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

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-20210219094337

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: PRUNERIDGE RESIDENTIAL CARE HOME	FACILITY NUMBER: 435201557
	VISIT DATE: 09/13/2021

NARRATIVE

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Resident fell while in care

Based on staff interviews, 4 out of 4 stated that they did not hear resident (R1) fall out of bed. All staff stated they found R1 already on the floor at around 8am on 02/19/21. One staff stated R1 was last checked around 7:10am that day while staff was doing rounds on the residents and R1 was awake and laying on the bed.

Licensee did not provide medical assistance in a timely manner

From staff interviews, 4 out of 4 staff stated that licensee was notified when R1 was found on the floor around 8am on 02/19/21. Temporary staff stated that they called the licensee several times that day as soon as they found R1 on the floor.

During licensee’s interview, licensee stated that she was notified of the incident around 8am that day. Licensee then notified the hospice nurse (RN) of the incident so they can check R1’s condition. Afterwards, licensee instructed the two temporary staff to take turns watching R1 until RN arrived at the facility. Licensee stated that RN called her after the visit and notified her that R1 was fine, was not in pain, there was no bruising, no bleeding, R1’s vitals were good and that R1 responds to RN. Licensee also stated that when the temporary staff notified her the next day that R1 has some bruising on the right leg, licensee called and reported the bruising to RN and was advised to ice the leg 3x a day.

On 05/17/21, LPA interviewed RN. During the interview, RN verified a call from the licensee was recorded on 02/19/21 at 8:49am to notify RN about the incident with R1. RN stated R1 was visited and checked the day of the report.

The department has completed the investigation of the above allegations. Based on interviews and records review, there is no preponderance of evidence to prove the allegations did or did not occur. Therefore, the Department found the above allegations to be UNSUBSTANTIATED.

No citations were issued per the California Code of Regulations, Title 22. Report was reviewed and a copy provided to Rosalia Calungcagin.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC9099 (FAS) - (06/04)

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