435201736-8-17-2023-26-AS-KHOS-CVCLTD-20230904090211

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201736
Report Date: 08/17/2023
Date Signed: 08/17/2023 09:41:21 AM

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
11/17/2020 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20201117113646

FACILITY NAME:	ABORN ADULT CARE HOME		FACILITY NUMBER:	435201736
ADMINISTRATOR:	DR. SHACY LEE RIVERA		FACILITY TYPE:	735
ADDRESS:	2868 ABORN ROAD		TELEPHONE:	(408) 223-1108
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	6	CENSUS: 1	DATE:	08/17/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Arielle Teodoro		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Staff did not provide adequate supervision.

INVESTIGATION FINDINGS:

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Licenisng Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. LPA met with Administrator Arielle Teodoro. It was alleged that resident (R1) would have consumed alcohol while under the supervision of staff.

On 11/30/2020, the Department conducted an initial 10-Day Investigation. During investigation, a tour of the facility was conducted via FaceTime due to pandemic restrictions. Then LPA Jackie Jin requested the following documents of R1 such as physician's report, needs and services plan, IPP, progress notes, current centrally stored medication record, MAR for October 2020, hospital discharge paperwork, and staff schedule for October 2020 and December 2020.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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-20201117113646

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: ABORN ADULT CARE HOME	FACILITY NUMBER: 435201736
	VISIT DATE: 08/17/2023

NARRATIVE

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On 11/17/2020, the Department received a complaint allegation from reporting party (RP) that R1 was not provided adequate supervision. Based on allegation reported, R1 had 3 seizures on 10/08/2020 requiring hospitalization. During R1's hospitalization, tests were ran on him/her showing a result of .04% alcohol. R1's MD stated that R1's prescribed medication does not alter the test results and alcohol had to be ingested.

On 02/23/2023, LPA Dolores conducted an interview with Administrator and staff. Based on interview with Administrator (ADM), ADM stated that R1 is unable to leave facility unassisted and is non-verbal. ADM stated that R1 visits his/her mother at home. R1 is assessed by staff after R1 spent time with his/her family. ADM stated that staff did not notice him/her smelling alcohol, nor disoriented. The facility does not allow consumption of alcohol nor do they have alcohol in the facility. R1 only drank soda and water. R1 is no longer residing at the facility.

On the same day, an interview with staff (S1) conducted. S1 stated that R1 is non-verbal and cannot leave facility unassisted requiring care and supervision. S1 stated that R1 was not seen drinking alcohol, he/she only consumed soda.

On 10/13/2020, the Department received an incident report from the facility stating that at 8:40AM, staff reported to ADM that R1 had a seizure and not responding to staff. 911 was called. R1 was taken the hospital and his/her parent accompanied him/her at the hospital. ADM stated that R1's parent reported that R1 was found to have low sodium and an elevated ammonia level. R1 was later evaluated by a neurologist at the hospital who attributed likely cause of R1's seizures to these abnormal levels that may have been due to discontinuation of 1 medication ordered by his/her neurologist.

On 07/18/2023, the Department conducted an interview with R1's service coordinator (SC) with San Andreas Regional Center (SARC). SC stated awareness of alcohol found in R1's body while at the hospital. The facility had an emergency meeting held on 10/23/2020 with R1's parent, SARC team, and ADM. SC stated that he/she was R1's SC for 4 years but never knew of R1 drinking.

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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20201117113646

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: ABORN ADULT CARE HOME	FACILITY NUMBER: 435201736
	VISIT DATE: 08/17/2023

NARRATIVE

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SC stated that ADM confirmed to him/her that R1 did not drink alcohol, nor did R1 swallow mouth wash. R1 was never around with alcohol in the facility. The incident occurred during pandemic wherein restrictions were in place, and the only time R1 left the home is when he/she spent time with parent(s) for an outing. SC stated that R1's mother assumed that his/her son was given an alcohol by the facility. SC stated that R1 is no longer under SARC as his/her parent moved him/her to another county.

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 allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Arielle Teodoro and a copy of the report was provided.

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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

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