435202338-11-21-2024-26-AS-KHOS-DBMNNP-20241204093703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202338
Report Date: 11/21/2024
Date Signed: 11/21/2024 12:31:15 PM

Unfounded

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
09/27/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240927165935

FACILITY NAME:	AMBROSIA SENIOR CARE		FACILITY NUMBER:	435202338
ADMINISTRATOR:	HELEN IBRAHIM		FACILITY TYPE:	740
ADDRESS:	1176 WESTWOOD DRIVE		TELEPHONE:	(408) 460-6656
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	6	CENSUS: 4	DATE:	11/21/2024
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Administrator Helen Ibrahim		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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A resident had a fall who sustained a fracture due to neglect/lack of supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPA met with Administrator Helen Ibrahim.

On September 27, 2024, the Department received a complaint alleging A resident had a fall, who sustained a fracture due to neglect/lack of supervision. It has also been alleged that R1 had sustained a fall on September 22, 2024, resulting in a fracture.

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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 5

Control Number 26-AS-20240927165935

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: AMBROSIA SENIOR CARE	FACILITY NUMBER: 435202338
	VISIT DATE: 11/21/2024

NARRATIVE

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On October 3, 2024, Licensing Program Analyst Manuel Monter interviewed ADM. ADM stated she was at the facility on September 22, 2024 and R1 had not sustained a fall in the facility. ADM stated she was informed by R1’s Power of Attorney (POA )on September 24, 2024, after R1 was taken to the hospital, that he/she took R1 out on an outing, on September 21, 2024, and R1 had hit his/her hand on the wheel chair. R1's POA stated R1 had stated "Oww", but stated to the POA that he/she was not experiencing pain. POA stated he/she did not inform the facility staff about R1 hitting his/her hand on the wheel chair.

Licensing Program Analyst Manuel Monter interviewed Staff S1 & S2. S1 stated he/she is a live in staff who resides in the staff room, directly next to R1’s bedroom. Staff S1 and S2 stated stated R1 didn’t have a fall in the facility. S1 and S2 stated they didn’t observe R1 sustaining a fall and did not find R1 on the ground.

Licensing Program Analyst Manuel Monter interviewed residents R1-R6. R1 stated R1 stated he/she did sustain a fall back in March 2023, in the hospital. R1 stated he/she has not fallen in the facility. R1 stated he/she did hit his/her hand when he/she went with his/her family member to the park.

LPA Monter interviewed 6 residents (R1-R6). 5 Out of 6 residents interviewed (R2-R5) stated they did not observe R1 sustain a fall in the facility on September 22, 2024. 1 Out of 6 residents interviewed (R6), is nonverbal and was unable to respond to LPA’s questions.

On November 12, 2024, LPA Manuel Monter interviewed R1’s Power of Attorney (POA). POA stated he/she was out with R1 on September 21, 2024, at a park. POA stated he/she was pushing R1 on wheelchair. POA stated he/she heard R1 say “ow”. R1 told POA that he/she banged his/her hand on the wheel of the wheelchair. POA asked R1 if he/she was ok. R1 stated he/she was not in pain. POA said he/she didn’t tell the staff, cause R1 stated he/she was fine.

POA stated then after a few days he/she was informed that R1 went to emergency due to pain on finger. POA stated R1 had a minor fracture on his/her pinky finger, which required a cast to be used for a couple weeks. POA stated R1 didn’t have a fall in the home. POA stated R1 just banged his/her hand on the wheelchair.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20240927165935

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: AMBROSIA SENIOR CARE	FACILITY NUMBER: 435202338
	VISIT DATE: 11/21/2024

NARRATIVE

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Based on a review of Facility Incident Report, dated October 3, 2024, emergency services were contacted for R1 on September 24, 2024, who stated he/she had fallen.

Based on a Review of R1’s Kaiser Permanente Progress Notes, dated October 20, 2024, R1 had injured his/her finger when he/she was out in the park with his/her family member on September 21, 2024. R1 hit his/her hand against the wheelchair armrest and R1 yelled “ouch.” The results of the X ray, state there was no acute fracture or dislocation.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Page 3 Out of 3. END OF REPORT.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
09/27/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240927165935

FACILITY NAME:	AMBROSIA SENIOR CARE		FACILITY NUMBER:	435202338
ADMINISTRATOR:	HELEN IBRAHIM		FACILITY TYPE:	740
ADDRESS:	1176 WESTWOOD DRIVE		TELEPHONE:	(408) 460-6656
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	6	CENSUS: 6	DATE:	11/21/2024
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Administrator Helen Ibrahim		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Faciity did not submit incident report.

INVESTIGATION FINDINGS:

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On September 27, 2024, the Department received a complaint alleging Facility did not submit incident report. It has been alleged the facility did not send an incident Report for a fall R1 sustained.

On October 3, 2024, Licensing Program Analyst Manuel Monter interviewed ADM. ADM stated she was informed by R1’s family member on September 24, 2024, that he/she took R1 out on an outing, on September 21, 2024, and R1 had hit his/her hand on the wheel chair the park and did not inform staff that day.

ADM stated on September 24, 2024, R1’s Therapist contacted 911, when he/she was informed by R1 about a fall. ADM stated she sent an incident report for this hospital visit.

Page 1 Out of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20240927165935

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: AMBROSIA SENIOR CARE	FACILITY NUMBER: 435202338
	VISIT DATE: 11/21/2024

NARRATIVE

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Licensing Program Analyst Manuel Monter interviewed resident R1. R1 stated he/she did hit her hand when he/she went with his/her family member and had hit her hand on the wheelchair when they were visiting the park.

On November 12, 2024, LPA Manuel Monter interviewed R1’s Power of Attorney (POA). POA stated he/she was out with R1 on September 21, 2024, at a park. POA stated he/she was pushing R1 on wheelchair. POA stated he/she heard R1 say “ow”. R1 told POA that he/she banged his/her hand on the wheel of the wheelchair. POA asked R1 if he/she was ok. R1 stated he/she was not in pain. POA said he/she didn’t tell the staff, cause R1 stated he/she was fine.

Based on a Review of R1’s Kaiser Permanente Progress Notes, dated October 20, 2024, R1 had injured his/her finger when he/she was out in the park with his/her family member on September 21, 2024. R1 hit her hand against the wheelchair armrest and R1 yelled “ouch.” The results of the X ray, state there was no acute fracture or dislocation.

Based on a review of facility Fax receipt, the facility sent a fax to CCL on September 25, 2024, at 4:32pm, which contained 2 pages. Furthermore, the fax receipt states the result of the fax was “ok.’ Based on a review of CCL fax records, the fax in question was not received.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Page 2 Out of 2. END OF REPORT

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

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