435202196-5-24-2023-26-AS-KHOS-CSHJ4Z-20230605064357

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202196
Report Date: 05/24/2023
Date Signed: 05/24/2023 11:55:34 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
01/03/2023 and conducted by Evaluator Christine Dolores

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230103140156

FACILITY NAME:	ELWYN NC - LA ALAMEDA		FACILITY NUMBER:	435202196
ADMINISTRATOR:	CANOSA, JOCELYN		FACILITY TYPE:	734
ADDRESS:	15470 LA ALAMEDA DR		TELEPHONE:	(408) 779-5353
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	5	CENSUS: 2	DATE:	05/24/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	NOBUHLE MANYIKA		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff did not change resident's urine tube for 3 weeks
Facility was not properly heated and did not maintain the warm temperature in the facility.
Facility staff did not dress resident appropriately which cause resident to have pneumonia.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings for the above allegations. LPA met with Administrator Nobuhle Manyika and Designated Administrator, Cynthia Octabiano.

On 01/03/2023, the Department received a complaint regarding the above allegations.

The following documents were obtained to include facility client roster, staff schedule from November 2022 – December 2022, foley catheter insertion policy and procedures, resident (R1)’s physician’s report, personal service plan, progress notes, temperature log, and medical records.

On 01/12/2023, the initial complaint investigation was conducted by LPA Dolores. During visit, LPA observed the facility’s thermostat was set at 72 degrees Fahrenheit. Three out of three residents joining an activity in the living room were observed wearing appropriate clothing. SEE LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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-20230103140156

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: ELWYN NC - LA ALAMEDA	FACILITY NUMBER: 435202196
	VISIT DATE: 05/24/2023

NARRATIVE

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R2 – R3 was wearing a long sleeve, pants, socks and was also provided a blanket. R4 was wearing a long jersey shirt, pants, and socks. Based on interview, the staff can observe if a resident is feeling cold. LPA observed the facility has enough blankets to provide each resident, if needed.

The Department of Developmental Services nurse consultant visited the facility on 01/11/2023. It was reported the facility’s thermostat was set to 72 degrees Fahrenheit and residents were observed appropriately dressed and all had blankets.

Based on research, pneumonia is not caught by low temperature or improper clothing (Nationwide Children’s, 2016); pneumonia may be caused by a variety of organisms including bacteria, viruses, or fungi (Mayo Clinic, 2023). The review of R1’s medical records indicate R1 is at risk for a condition which may be a cause of pneumonia.

On 11/26/2022, resident (R1) returned to the facility with a foley catheter. The facility was provided at-home general instructions by the hospital, to include but not limited to instructions on medicines, hydration, monitoring for vitals and changes in symptoms, and follow-up appointments. Based on record review, the facility was not provided instructions from a medical professional, to include a physician’s order, to change the resident’s urine tube. The facility was also not provided information on the brand of the catheter to possibly follow the manufacturer’s instructions.

From 11/27/2022 – 12/09/2022, R1 was being monitored and observed by staff every shift to include R1’s vitals and observation of R1’s foley catheter device of being intact, draining, observation of color and odor.

Based on record review, interview, and observation the Department has investigated the above allegations to be unsubstantiated. An unsubstantiated finding means although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Nobuhle Manyika and Designated Administrator, Cynthia Octabiano and a copy of the report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

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