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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201796
Report Date: 07/21/2023
Date Signed: 07/21/2023 03:28:23 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
02/17/2022 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20220217145558
FACILITY NAME:NUEVA VISTAFACILITY NUMBER:
435201796
ADMINISTRATOR:WEINSTEIN, MICHAELFACILITY TYPE:
735
ADDRESS:18225 HALE AVENUETELEPHONE:
(408) 465-8280
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:72CENSUS: 64DATE:
07/21/2023
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Ethelind LaraTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Facility prohibits resident to return to facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. The facility’s Administrator and management team was attending a training in Sacramento and was unable to meet LPA at the facility. LPA met with Medroom Manager / Manager on Duty, Ethelind Lara.

On 02/17/2022, the Department received the complaint. On 02/23/2022, the initial complaint investigation was conducted.

The following documents were obtained to include the facility’s resident roster, February 2022 staff schedule, resident (R1)’s 72-hour assessment, physician’s report, and appraisal/needs and services plan.

SEE LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
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 2
Control Number 26-AS-20220217145558
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: NUEVA VISTA
FACILITY NUMBER: 435201796
VISIT DATE: 07/21/2023
NARRATIVE
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On 02/14/2022, it was alleged resident (R1) was prohibited to return to the facility after being discharged from Emergency Psychiatric Services (EPS). On 02/23/2022, 4 staff members were interviewed. Based on interviews, it was observed R1’s health was declining which prompted the facility to transport R1 to EPS. S1 states R1 was not necessarily prohibited from returning as there was prior arrangements for R1’s county coordinator to pick-up R1 up from EPS. S3 states the facility was in contact with R1’s county coordinator that day which it was agreed upon R1 returning to their original county to receive higher level of care.

Based on interviews, R1’s county coordinator was responsible to coordinate pick-up for R1 at EPS.

The review of records shows R1 was provided a 72-hour assessment. The assessment listed an order of preference to transfer R1 back to their original county after receiving a medical clearance from EPS.

The Department has investigated the above allegation. Based on interview, record review and observation the Department has found the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to provide the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Medroom Manager / Manager on Duty, Ethelind Lara. and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2