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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201646
Report Date: 12/11/2024
Date Signed: 12/11/2024 05:19:55 PM

Substantiated


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
12/04/2024 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20241204145258
FACILITY NAME:K & N MANOR, INC.FACILITY NUMBER:
435201646
ADMINISTRATOR:REMEDIOS BOSEFACILITY TYPE:
735
ADDRESS:2420 BRIDLE PATH DRIVETELEPHONE:
(408) 846-0819
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:6CENSUS: 5DATE:
12/11/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Remedios "Remy" BoseTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility did not provide night supervision to meet the needs of resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Christine Dolores and Kenneth Madrigal arrived unannounced to open the initial complaint investigation. LPAs met with Administrator, Remedios “Remy” Bose.

On 12/04/2024, the Department received the complaint. On 12/11/2024, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include 5 residents physician’s report and appraisal/needs and services plan; R1 – R2’s progress notes, medical discharge paperwork, medication administration records, centrally stored medication record; staff schedule, and client roster.

It was alleged that the facility did not provide night supervision to meet the needs of residents. On 12/02/2024, a resident (R1) was taken to urgent care by staff when it was found that R1 had multiple rib fractures. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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-20241204145258
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: K & N MANOR, INC.
FACILITY NUMBER: 435201646
VISIT DATE: 12/11/2024
NARRATIVE
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When asked how the resident sustained the multiple rib fractures, the staff was unable to provide an answer. It was mentioned that the facility does not have night supervision to know if the resident may have had a fall or unusual incident during the night.

On 12/11/2024, the Administrator was interviewed. Based on interview with the ADM, on 12/02/2024 ADM observed R1 had cough and cold symptoms at day program which prompted ADM to take R1 to urgent care. At urgent care, it was found that R1 had multiple rib fractures. The reason for how R1 sustained multiple rib fracture is unknown. It was stated that the facility does not have an awake night staff to know if the resident may have had a fall or unusual incident during the night. 3 staff members were interviewed. During staff interviews, it was stated that R1 started to show symptoms starting on 11/29/2024 of a light cough, difficulty standing for a long period of time, shortness of breath, slouching, and difficulty hunching over to put his/her socks on. Staff believed R1 only had a cold and was providing R1 water from Friday – Sunday. On Monday, 12/1/2024, staff observed that R1’s condition was not improving and was brought to urgent care where it was found that R1 sustained multiple rib fractures. Staff was unsure how R1 sustained the multiple rib fractures as they do not have an awake night staff to observe if R1 had a fall or unusual incident the night before.

Based on record review of R1's IPP, it states that "R1 has an additional NOC staff on the schedule due to nighttime wakefulness and to ensure his/her health and safety". The review of the facility’s direct care staff schedule shows that the facility schedules an awake night staff from 11PM – 6AM, however, based on interview with the Administrator, the facility actually does not have an awake night staff. 3 out of 3 staff also confirmed that the facility does not have an awake night staff.

The Department has investigated the above allegation. Based on interview, record review and observations the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. See LIC9099-D. A case management – deficiencies visit was conducted due to violations observed during the investigation. This report was reviewed with Administrator, Remedios “Remy” Bose and a copy of the report and appeal rights was provided. Page 2 of 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20241204145258
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: K & N MANOR, INC.
FACILITY NUMBER: 435201646
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2024
Section Cited
CCR
85065.6(g)
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(g) In facilities providing care to Regional Center clients who rely upon others to perform all activities of daily living, night supervision shall be maintained as required by the Regional Center, but no less than the staff-client ratio specified in Sections 85065.6(f) and (f)(1). This requirement is not met as evidenced by:
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Licensee states there will schedule an awake night staff that will be scheduled starting today and going forward. Licensee will submit a statement of understanding of the regulation regarding required
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Based on interview, record review and observation the licensee did not ensure to have an awake night staff as per their staffing schedule, which is required by the Regional Center which poses/posed an immediate health, safety, and personal rights risk to persons in care.
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night supervision. Licensee will submit the statement of understanding to LPA Dolores via email by POC due date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
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