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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202293
Report Date: 04/17/2024
Date Signed: 04/17/2024 11:32:19 AM

Substantiated


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
04/10/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240410110758
FACILITY NAME:KB CARE HOMEFACILITY NUMBER:
435202293
ADMINISTRATOR:KAITLYN BROWNELLFACILITY TYPE:
735
ADDRESS:1948 SEABEE PLACETELEPHONE:
(408) 823-6734
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY:6CENSUS: 5DATE:
04/17/2024
UNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Administrator Kaitlyn BrownellTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff did not accompany resident to a medical appointment
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Manuel Monter and Christine Dolores conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPAs met with Administrator (ADM) Kaitlyn Brownell.

On April 10, 2024, the Department received a complaint alleging Staff did not accompany resident to a medical appointment.

Page 1 Out of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
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 3
Control Number 26-AS-20240410110758
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: KB CARE HOME
FACILITY NUMBER: 435202293
VISIT DATE: 04/17/2024
NARRATIVE
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On April 10, 2024, the Department received an incident report from the facility which stated the following: On March 28, 2024, staff alerted the ADM around 7:15pm due to R1’s labored breathing. Staff were concerned that R1 might need urgent care or medical attention due to his/her difficult breathing. ADM called R1’s conservator but he/she did not answer. Staff were instructed to call paramedics if they are concerned about R1’s breathing. Paramedics arrived and but could not get in touch with R1’s conservator. Paramedics took R1 and staff are not allowed to ride with individual in ambulance. R1’s conservator dropped R1 off at the care home just after midnight.

On April 17, 2024, LPA Manuel Monter interviewed Witness 1 (W1). W1 stated he/she was contacted by the hospital and was informed that R1 was at the hospital alone. W1 stated when he/she arrived at the hospital, he/she did not observe any staff or the facility Administrator with R1. W1 stated he/she stayed with R1 while until they finished their tests and returned R1 to the care home after midnight.

On April 17, 2024, LPA's Dolores and Monter interviewed ADM. ADM stated she did everything she could do to communicate with R1's conservator. ADM stated that the emergency room was not a good setting for R1 due to his/her behaviors. ADM stated staff did not go with R1 to the hospital.

Based on a review of R1, Individual Program Plan, dated September 16, 2022, R1 requires constant supervision during waking hours to prevent injury/harm in all settings.

Based on interviews and evidenced reviewed the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with Administrator Kaitlyn Brownell and a copy of the report was provided. Appeal Rights was provided.

Page 2 out of 2.

END OF REPORT
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20240410110758
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: KB CARE HOME
FACILITY NUMBER: 435202293
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2024
Section Cited
CCR
85078(a)(1)
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85078 Responsibility for Providing Care and Supervision (a)(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
This requirement has not been met as evidenced by;
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ADM stated she will send a letter of understanding regarding the regulation and how she will ensure residents are being supervised to meet their needs.
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Based on records reviewed and interview conducted, ADM confirmed staff was not with R1, during his/her stay at the hospital. R1's IPP states R1 requires supervision to prevent injury/harm in all settings. This poses an immediate threat to health, safety and personal rights risk to person in care.
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ADM stated she will send the plan of correction by POC date, April 18, 2024.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3