435201951-6-10-2020-26-AS-SYIP-BQNSDE-20200617134700

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201951
Report Date: 06/10/2020
Date Signed: 06/10/2020 04:39:49 PM

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
11/14/2019 and conducted by Evaluator James G Santos

COMPLAINT CONTROL NUMBER: 26-AS-20191114115506

FACILITY NAME:	PENDAR'S RESIDENTIAL CARE		FACILITY NUMBER:	435201951
ADMINISTRATOR:	MILA VALISTO		FACILITY TYPE:	740
ADDRESS:	515 TUSCARORA DR.		TELEPHONE:	(408) 578-6785
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 6	DATE:	06/10/2020
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Mila Valisto.		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are failing to ensure that the resident's medical needs are met.
Facility does not have planned activities for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) James Santos conducted an unannounced tele-visit today to deliver the investigation findings on the above allegations. Due to the current COVID-19 situation, LPA met with assistant administrator, Mila Valisto via tele-conference.

On 11/21/2019, the initial investigation visit was conducted. During initial visit at around 5:00pm, LPA obtained copies of resident's (R1) physician's report, needs and services plan, progress notes, conservatorship letter and facility residents roster.

On 1/31/2020, a subsequent visit was conducted. During visit at around 2:15pm, LPA conducted interviews with 5 residents which includes R1 and 5 staff.

Two out of the 5 residents stated that there are activities in the home, however, one was unable to specify while the other (R1) wishes there are more activities in the home. Two out of the 5 residents stated there are no activities in the home.

Continued on page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2020

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-20191114115506

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: PENDAR'S RESIDENTIAL CARE	FACILITY NUMBER: 435201951
	VISIT DATE: 06/10/2020

NARRATIVE

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Also based on interview, R1 does not like going to the doctor. One out of the 5 residents stated she talks to her doctor on the phone and another resident stated he drives himself to the doctor. One out of the 5 residents was unable to communicate.

All 5 staff interviewed stated their residents do not like to do or join the activities. The residents prefer walking outside or work in the yard. Staff stated they encourage their residents to do activities but their residents have different cognitive levels so they sometimes won’t do the activity. Staff stated that they have stuff that are readily available in their living room like puzzles, bingo and arts and crafts.

Staff stated that they are responsible in scheduling their residents' medical appointments. Per interview with
staff, R1 has been going to the doctor regularly after moving into the facility and then after a while, R1 started refusing. Staff documented the dates R1 refused to go to the doctor on their progress notes. The review of R1’s progress notes confirmed the statements of staff regarding R1’s refusal and noted multiple times R1’s doctor made home visits instead.

On 5/20/2020, LPA spoke with R1's Conservator via telephone. Per interview, Conservator is aware that R1 does not like going to the doctor and dentist. Conservator stated there were times R1 refused to get out of the car while out in the parking lot and there were times R1 does not even want to get in the car to go to the appointment. Conservator also stated that R1 has a lump on the head which is benign and per the doctor, it is better to leave the lump alone since it is not malignant.

During the course of investigation, copies of residents' medical records between 2018 - 2020 were obtained and noted that the residents have been visiting their doctors. Facility does not have any resident with wounds or medical conditions that needs attention.

On 6/9/2020, LPA spoke with the licensee via telephone. Per interview, licensee stated they don’t have scheduled activities because not all residents are able to participate in certain activity like bingo. Licensee stated they instead engage their residents with individual activities based on their interests and cognitive level like arts and crafts, puzzles and walking. Licensee stated she never stopped their activities because that would not be providing care to the residents.

Continued on page 3

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20191114115506

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: PENDAR'S RESIDENTIAL CARE	FACILITY NUMBER: 435201951
	VISIT DATE: 06/10/2020

NARRATIVE

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During subsequent visits, LPA observed staff doing arts and crafts activity with the residents. LPA also observed the facility's activity stuff like puzzles, bingo and arts and crafts that are readily available in their living room.

The Department has investigated the above allegations and based on the interviews, observations and review of records, although the allegations may have happened or are valid, there are no preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed on 6/10/2020 to the assistant administrator for signature.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2020

LIC9099 (FAS) - (06/04)

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