435202301-2-8-2024-26-AS-KHOS-D2LVYF-20240219155104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202301
Report Date: 01/08/2024
Date Signed: 02/08/2024 03:58:44 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2022 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220225121016

FACILITY NAME:	PALM VILLAS, CAMPBELL		FACILITY NUMBER:	435202301
ADMINISTRATOR:	SNEPER, GARRY		FACILITY TYPE:	740
ADDRESS:	3333 SOUTH BASCOM AVENUE		TELEPHONE:	(408) 559-8301
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	48	CENSUS: 41	DATE:	01/08/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Myra Belza & Blyth Obien		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident not administered medication as prescribed.

INVESTIGATION FINDINGS:

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This is an amended Report

On 1/08/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Office Manager Myra Belza & Resident Services Director Blyth Obien. LPA explained the purpose of the visit.

Regarding the allegation of resident not administered medication as prescribed, reporting party (RP) stated he/she believes the resident (R1) was overdosed on medication since 2021.

R1 is prescribed multiple medications. RP is alleging that these medications are used to calm R1 down and restraint due to behavioral issues.

cont.. 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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-20220225121016

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: PALM VILLAS, CAMPBELL	FACILITY NUMBER: 435202301
	VISIT DATE: 01/08/2024

NARRATIVE

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Based on interviews by LPA Heberle, two staff members mentioned that there never was an issue of residents having mismanagement of medications. On staff member (S1) stated that the facility does not have any involvement in which medications residents are taking. The family can make request that the facility administer certain medications, but staff always makes sure the doctor okays and prescribes it first. The facility communicates with doctors if they believe the medication needs to be changed. LPA Heberle & LPA Donato was also able to interview residents and two out of five mentioned that they don’t have any issues with medications, and they are able to get it on time. Three residents were not able to respond to questions due to cognitive diagnosis..

LPA Donato was able to review records for R1, and according to the centrally stored medication, facility gave the medication according to doctors’ orders.

Therefore, based on the interviews conducted, files reviewed, and information collected, the allegations mentioned are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

The report was reviewed, and a copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC9099 (FAS) - (06/04)

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