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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202301
Report Date: 05/06/2021
Date Signed: 05/06/2021 02:16:39 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2020 and conducted by Evaluator Marybeth Donovan
COMPLAINT CONTROL NUMBER: 26-AS-20200221091058
FACILITY NAME:PALM VILLAS, CAMPBELLFACILITY NUMBER:
435202301
ADMINISTRATOR:SNEPER, GARRYFACILITY TYPE:
740
ADDRESS:3333 SOUTH BASCOM AVENUETELEPHONE:
(408) 559-8301
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:48CENSUS: 27DATE:
05/06/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Brisa RomeroTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident developed multiple pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Tele-Visit due to COVID-19 Pandemic restrictions to deliver the complaint investigation finding. LPA met with Brisa Romero Administrator.

The reporting party stated that R1 had sores on R1's feet that were unnoticed and untreated.

Site visit was conducted on 2/26/2020. Telephone interviews were conducted between 2/26/2020 and 4/12/2021. 8 staff and 3 medical professionals were interviewed. Records obtained and reviewed included resident (R1) admission records, assessments, physician’s report, hospital records, doctor communications and order’s, outside home health agency communications and facility reports.

8 out of 8 staff interviewed denied R1 had pressure injuries on his heels. 3 out of 3 medical professionals did not observe pressure injuries to R1’s heels. Staff also indicated that they turned R1 every 2 hours and R1’s wounds were improving and almost cleared up.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
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 5
Control Number 26-AS-20200221091058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: PALM VILLAS, CAMPBELL
FACILITY NUMBER: 435202301
VISIT DATE: 05/06/2021
NARRATIVE
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Resident Records reviewed for the period of 4/15/2019 through 2/21/2021 noted that on 4/15/2019 R1 physical condition was assessed upon admission and observed to have dry skin on both heels. On 5/17/2019 R1 was diagnosed with pressure injury to left heel. Home Health services completed 7 visits from 5/10/2019 through 6/13/2019 for foot care. Treatment was completed on 6/13/2019. There was no reoccurrence of this of pressure injury. R1 continued to receive home health care for the other wounds until August, 2019 when all wounds were completely healed. Home health notes dated 6/28/19 and 8/8/19 stated no wound on legs, and no broken skin and no pressure wound noted respectively. Doctor’s order dated 8/6/19 noted all affected areas appear healed.

On 2/12/2020 Home Health notes indicated blister on heel. R1’s PCP was notified, and no treatment ordered. On 2/13/2020 PCP was updated as to R1’s condition and no treatment ordered. R1 was admitted to hospice services on 2/14/2020.

Records indicated R1 had chronic pressure injuries to other areas of R1’s body. R1 was treated at a wound clinic once a week and seen by outside home health medical professionals weekly for assessment and care.

Per interview with the resident's primary care physician (PCP), R1's other pressure injuries were from longstanding case of R1’s medical condition and incontinence. PCP stated that the wounds have been healing. PCP did not feel R1's wounds or injuries were signs of abuse or neglect.

The review of police report dated 5/3/19 noted case was closed as there was no indication of adult abuse.

The Department has investigated the complaint allegation listed. Based on interviews conducted and records reviewed, the Department has found that the complaint allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Report reviewed with Brisa Romero Administrator and a copy of this report emailed for signature.



SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2020 and conducted by Evaluator Marybeth Donovan
COMPLAINT CONTROL NUMBER: 26-AS-20200221091058

FACILITY NAME:PALM VILLAS, CAMPBELLFACILITY NUMBER:
435202301
ADMINISTRATOR:SNEPER, GARRYFACILITY TYPE:
740
ADDRESS:3333 SOUTH BASCOM AVENUETELEPHONE:
(408) 559-8301
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:48CENSUS: 27DATE:
05/06/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Brisa RomeroTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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5
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9
Resident was left in soiled clothing for an extended period of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Tele-Visit due to COVID -19 Pandemic restrictions to deliver the complaint investigation findings. LPA met with Brisa Romero Administrator.

Site visit was conducted on 2/26/2020. Between 2/26/2020 and 4/12/2021, telephone interviews were conducted. 8 staff and 3 medical professionals were interviewed. Records obtained and reviewed included resident (R1) admission records, assessments, physician’s report, hospital records, doctor communications and order’s, outside home health agency communications and facility reports.

8 out of 8 staff stated that R1’s diaper was checked at a minimum every hour to 2 hours or as needed. R1 was not left in soiled diaper or clothing for an extended period of time.

3 out of 3 medical professionals interviewed did not have concerns or issues with R1’s incontinence care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20200221091058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: PALM VILLAS, CAMPBELL
FACILITY NUMBER: 435202301
VISIT DATE: 05/06/2021
NARRATIVE
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Medical records reviewed included Outside Home Health Agency Communications which did not indicate any issues with incontinence care.

The Department has investigated the above allegation. Based on information from interviews conducted and records reviewed, although the allegations listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22

Report reviewed with Brisa Romero Administrator and a copy of this report emailed for signature.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5