435201796-12-15-2021-26-AS-KHOS-CA4QUQ-20211227112907

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201796
Report Date: 12/15/2021
Date Signed: 12/15/2021 03:54:55 PM

Unsubstantiated

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
09/23/2021 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20210923085230

FACILITY NAME:	NUEVA VISTA		FACILITY NUMBER:	435201796
ADMINISTRATOR:	WEINSTEIN, MICHAEL		FACILITY TYPE:	735
ADDRESS:	18225 HALE AVENUE		TELEPHONE:	(408) 465-8280
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	72	CENSUS: 68	DATE:	12/15/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Samiha Faour		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility does not advise residents of their personal rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores conducted unannounced complaint visit to deliver findings of the above allegations. LPA met with Samiha Faour, Program Coordinator in-person and Arturo Uribe, CEO and Michael Weinstein, Administrator via FaceTime.

From 09/30/2021 – 11/29/2021, LPA obtained the following documents to include: R1 – R6 Physician Reports, Appraisal Needs and Services Plan, Personal Rights Form, Personnel Record, and Resident Community Rules.

On 11/04/2021, a total of 6 residents (R1 – R6) were interviewed. 2 out of 6 residents states the staff has gone over their personal rights during the admission process. 3 out of 6 residents states the staff sometimes or did not go over their personal rights during the admission process. 1 out of 6 residents did not comment.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

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-20210923085230

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: NUEVA VISTA	FACILITY NUMBER: 435201796
	VISIT DATE: 12/15/2021

NARRATIVE

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3 out of 6 residents stated knowing where the personal rights poster was located in the facility. 1 of 6 residents did not know where the personal rights poster was located. 2 of 6 residents did not comment on the location of the personal rights poster.

On 11/29/2021, a total of 6 staff (S1 – S6) were interviewed. 6 out of 6 staff stated they have been trained annually on resident’s personal rights. 5 out of 6 staff states knowing where the resident’s personal rights poster was located in the facility. 1 out of 6 staff states not knowing where the resident’s personal rights poster was located. 4 out of 6 staff stated residents are not allowed to have extension cords due to safety reasons. 2 out of 6 staff did not know about the extension cord policy.

During LPA visit on 09/30/2021, LPA observed resident’s mental health patients’ rights and rights of resident councils located on a bulletin board in the hallway.

Based on record review of R1 – R6, 6 out of 6 residents personal rights form was signed and dated by themselves, a conservator, public guardian, or responsible party. Resident Community Rules indicate that due to conservation and safety concerns residents may not have extension cords (only with Administrator approval).

The Department has investigated the above allegations. Based on interviews conducted, observation, and records reviewed, the Department has determined that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies cited per California Code of Regulations, Title 22.

This report was reviewed with Samiha Faour, Arturo Uribe, and Michael Weinstein and a copy of the report was provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

LIC9099 (FAS) - (06/04)

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