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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201710
Report Date: 12/28/2023
Date Signed: 12/28/2023 04:35:31 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
06/20/2023 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20230620162339
FACILITY NAME:KERN A.R.F.FACILITY NUMBER:
435201710
ADMINISTRATOR:SASHI KUMARFACILITY TYPE:
735
ADDRESS:2785 KERN AVE.TELEPHONE:
(408) 281-7057
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 4DATE:
12/28/2023
UNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Administrative Assistant Ernie ManaoisTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff refused to administer resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrative Assistant (AA) Ernie Manaois.

On June 20, 2023, the Department received a complaint alleging facility staff refused to administer resident R1’s medications on May 14, 2023, and June 19, 2023.

On June 28, 2023, LPA Ryker Heberle interviewed Administrative Assistant. (AA). AA stated R1 was making false statements about not taking his/her medications. AA stated no residents have had missed medications.

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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
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 3
Control Number 26-AS-20230620162339
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: KERN A.R.F.
FACILITY NUMBER: 435201710
VISIT DATE: 12/28/2023
NARRATIVE
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On November 01 and December 5, 2023, LPA Monter interviewed AA. AA stated staff would offer R1 his/her evening medication before he/she left for the day, but R1 would refuse and state he/she would take the medication when he/she returns to the facility. AA stated R1 would not tell staff when he/she would return to the facility. AA stated the PM medications are given after the resident’s dinner.

AA stated on May 14, 2023, S1 worked the whole day and on June 19, 2023, AA worked the morning shift, and S1 worked the evening shift. AA stated the residents should be home between 9:00pm - 10:00pm. AA stated there is no set bed time.

On October 21 & November 14, 2023, LPA Monter interviewed 5 Out of 5 residents. 4 Out of 5 residents denied the allegation and stated the facility staff provide their medications. 1 Out of 5 residents stated staff told him/her that his/her medications won’t be administered because he/she arrived home late.

On October 21, 2023, LPA randomly audited 2 resident medication records for the month of October. The medication audit was completed by cross-referencing the residents’ medications containers with the Centrally Stored Medication log and the Medication Administration Record. As a result, LPA did not find any discrepancies on medications.

LPA also reviewed R1’s Medication Administration Record (MAR), for the month of May 2023 showing all medications were administered, including May 14, 2023, and signed off by staff S1. A Review of R1’s MAR for the month of June 2023 shows staff initialed by AA and S1 on the MAR that on June 19, 2023, the medication was given. Further review of R1’s June 2023 MAR shows several dates were not initialed from June 21-27, 2023, which includes 5 days of PM medication.

On December 27, 2023, LPA interviewed AA & S2. S2 stated the medications are administered to the residents and staff do not refuse to administer residents medications. S2 stated if a resident comes home late, staff will provide residents their medications. AA stated regarding the instances where the MAR wasn't signed, the staff must of forgotten to sign. AA stated the staff administer the residents medications, even if the residents arrive home late.


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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 26-AS-20230620162339
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: KERN A.R.F.
FACILITY NUMBER: 435201710
VISIT DATE: 12/28/2023
NARRATIVE
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LPA attempted to interview staff S1, but he/she no longer works at the facility. AA stated S1’s was last employed on August 2023.

A review of R1’s Appraisal/ Needs and Services plan (ANS) dated October 26, 2022, states R1 has a mental disorder. R1 also experiences symptoms of delusional ideations.

Based on the interviews conducted with residents and staff & 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.

This report was reviewed with AA Ernie Manaois. A copy of this report was provided during exit interview.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3