435202351-12-21-2022-26-AS-KHOS-CTLGNW-20230710053010

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202351
Report Date: 12/20/2022
Date Signed: 12/21/2022 08:47:40 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/05/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220505142907

FACILITY NAME:	BELMONT VILLAGE SUNNYVALE		FACILITY NUMBER:	435202351
ADMINISTRATOR:	LOLA BULLOCK		FACILITY TYPE:	740
ADDRESS:	1039 E EL CAMINO REAL		TELEPHONE:	(408) 720-8498
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	150	CENSUS: 119	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Joshua Lambengco		TIME COMPLETED:	11:59 AM

ALLEGATION(S):

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Resident sustained a fracture while in care.
Resident did not receive medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation visit to deliver the investigation finding to the above allegations and met with Director of Resident Care Joshua Lambengco (JL)

On 05/05/2022, the Department received a complaint with above allegations.

On 5/6/2022, the Department conducted an initial investigation visit. Resident's file, care plan, incident reports, resident’s physician report, appraisal needs and services plan, and admission agreement were obtained. On 5/17/22 & 5/30/22, medical records from the hospitals were requested. Medication Administration Records (MAR) were obtained on 11/1/2022.

Continued, see LIC 9099-C, pages 1 of 3.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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 7

Control Number 26-AS-20220505142907

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BELMONT VILLAGE SUNNYVALE	FACILITY NUMBER: 435202351
	VISIT DATE: 12/20/2022

NARRATIVE

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Wellness communication notes were reviewed and noted on 3/18/22, R1 was found on floor at 0710 and 911 was called. R1 returned the same day and then on 3/19/22, R1 was found on floor at 0500 and again around 1202PM, R1 had an unwitnessed fall. Nothing was noted regarding the use of walker which corroborated with the staff interview on no new instruction was given after the first fall.

The review of MAR of March and April 2022 noted several medications (Miralax, Metformin, Insulin to name a few) were not given to R1 per doctor’s orders (11 days in March and 8 days in April) with no staff initials and no reasonable explanation as to why they were not given or missed.

1 Out of 1 staff interviewed stated MAR would specify the reason why a resident missed the medication.

The Department has investigated the above allegations. Based on records reviews, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D.

An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. An additional Civil Penalty in the amount of $10,000.00 for violation resulting in serious bodily injury is pending review.

Exit interview was conducted with JL. This report and LIC9099-D were provided to JL.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 26-AS-20220505142907

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BELMONT VILLAGE SUNNYVALE	FACILITY NUMBER: 435202351
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/26/2023 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to conduct staff training in ensuring care and supervision are provided to residents whose conditions have changed due to medical assessment or observations with updated care plans and submit the training plan to CCL by POC date.
	8 9 10 11 12 13 14	Based on document review and investigation, there was no evidence that the facility reassessed R1 after the fall. R1’s Reappraisal was not updated for the facility to develop the care plan to meet resident’s needs. This poses an immediate risk to the health of the resident.	8 9 10 11 12 13 14
Type A 07/26/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	(a) (4) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Facility did not discuss plan of care instruction with staff to ensure R1 receive the care and supervision	1 2 3 4 5 6 7	Licensee agrees to submit plan in writing on care and supervision of residents such as but not limited to falls to CCL by POC date.
	8 9 10 11 12 13 14	as a result R1 had 3rd fall sustained a right hip fracture. This poses an immediate risk to the health of the resident.This requirement was not met as evidence by: Based on investigation record review and interview, the facility did not update the care plan for R1 to ensure that resident received care, supervision and services that meet resident’s needs.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/05/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220505142907

FACILITY NAME:	BELMONT VILLAGE SUNNYVALE		FACILITY NUMBER:	435202351
ADMINISTRATOR:	LOLA BULLOCK		FACILITY TYPE:	740
ADDRESS:	1039 E EL CAMINO REAL		TELEPHONE:	(408) 720-8498
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	150	CENSUS: 119	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Joshua Lambengco		TIME COMPLETED:	11:59 AM

ALLEGATION(S):

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Motion detector in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation visit to deliver the investigation finding, and met with Director of Resident Care Joshua Lambengco (JL) .

On 05/05/2022, the Department received a complaint with above allegation that motion detector in disrepair. On the same day, the Department conducted an initial investigation visit. Resident's file, care plan, incident reports, resident physician report, appraisal needs and service plan, and admission agreement were obtained.

Continued on see LIC 9099-C. pages 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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 7

Control Number 26-AS-20220505142907

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BELMONT VILLAGE SUNNYVALE	FACILITY NUMBER: 435202351
	VISIT DATE: 12/20/2022

NARRATIVE

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation visit to deliver the investigation finding and met with Executive Director Lola Bullock (ED).

On 05/05/2022, the Department received a complaint with the above allegation. On the same day, the Department conducted an initial investigation visit. Resident's file, care plan, incident reports, resident physician report, appraisal needs and service plan, and admission agreement were obtained.

On 11/01/2022, LPA tested the motion detector in randomly selected rooms and interviewed ED. The motion detector was deemed functioning. ED stated the facility partners with Safely You who maintains the camera system with motion detector to evaluate the impact of artificial intelligence in detecting falls. ED stated Safely You monitors the camera system, uploads the fall videos, and notifies the facility through phone calls and emails on resident’s fall. ED stated the facility staff will immediately help residents who fell when staff received phone calls or emails from Safely You.

On 11/01/2022 and 11/03/2022, LPA interviewed Safely You Clinical Success Manager (AH) who stated that Safely You has a 24/7 team monitoring the camera system. The team will send alarm notifications, emails, and calls the facility to notify the fall of resident and upload the videos. AH also stated that Safely You will fix any problem or issue with the camera system.

For the fall of R1 on 3/19/2022, the camera system did not capture the fall. ED stated the following statements were provided to residents on the use of the camera system: "The camera system will be a supplement to the fall procedures, not a replacement." ; "The camera system is not 100% accurate, and falls could be missed even with the system in place due to technical issues." And “Cameras will be located solely in the bedroom and primary camera focus will be around the bed area.”

Continued on LIC-9099-C. Pahe 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 26-AS-20220505142907

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BELMONT VILLAGE SUNNYVALE	FACILITY NUMBER: 435202351
	VISIT DATE: 12/20/2022

NARRATIVE

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The admission agreement and documents on Safely You motion detector were reviewed and noted they corroborated with the ED and AH’s statements that Safely You is responsible for the motion detector and that this system may not capture every fall due to the field of view limitation.

Based on observations, documents review, and interviews conducted, the Department found that the above allegation is 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 allegation did or did not occur.

No deficiencies or citations noted at today’s compliant investigation visit.

Exit interview conducted with JL. A copy of this report was provided to JL.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 26-AS-20220505142907

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BELMONT VILLAGE SUNNYVALE	FACILITY NUMBER: 435202351
	VISIT DATE: 12/20/2022

NARRATIVE

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The review of hospital records noted on 3/18/22, R1 was taken to the ER due to unwitnessed fall. The discharge care includes the importance of assistance with ambulation and walker use. It was further noted that on 3/19/22, R1 arrived at 1330 hours because of unwitnessed fall with suspected head strike. X-ray showed right femoral intratrochanteric fracture. R1 underwent hip surgery and was discharged to SNF on 3/23/22.

Between 06/29/2022 and 09/17/2022, the Department interviewed 4 memory care unit residents including the victim (R1), a family member (FM), and 6 staff including the Executive Director (ED). On 11/1/22, additional 1 staff and ED again were interviewed.

4 Out of 4 residents were unable to provide details or information on falls.

ED, during interview, admitted to receiving the discharge papers on 3/18/22 fall. Per ED, after the first fall, clinical team (med tech, nurse, wellness coordinator) would contact family for a mediation plan. ED, however, was not able to produce any document to prove this occurred. ED stated R1’s existing plan of “observe closely” was appropriate as other plans were in place like half bed rail, Safely You detector, and hourly check.

6 Out of 6 staff interviewed stated fall risk residents are checked every hour and there was no new instruction other than to monitor closely for R1 after 3/18/22 fall.

The review of R1’s Appraisal Needs and Services (ANS) plan dated 2/3/2022 noted under Physical, it reads: “Fall risk, check resident; Physical – fall risk, escort/assist to/from activities and dining room daily.” Under Redirection and Guidance, it reads “staff provide additional interventions to manage exit seeking behavior because resident is a high fall risk. Redirection for all 3 shifts.” There was nothing noted on the use of walker. ANS was not updated to include the use of walker as instructed on the discharge summary care of 3/18/22.

Continued, see LIC 9099-C. page 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

Page: 7 of 7