435202380-10-6-2023-26-AS-RMAO-CWJJPN-20231012071346

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202380
Report Date: 10/04/2023
Date Signed: 10/06/2023 03:49:36 PM

Unsubstantiated

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
03/27/2023 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230327135941

FACILITY NAME:	EBADAT RESIDENTIAL CARE HOME #3		FACILITY NUMBER:	435202380
ADMINISTRATOR:	JOCELYN REAL		FACILITY TYPE:	735
ADDRESS:	4243 ROSENBAUM AVE.		TELEPHONE:	(408) 224-3716
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	6	CENSUS: 6	DATE:	10/04/2023
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Administrator, Aaron Coronel		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff caused injuries to a client while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Simi Rai and Steve Chang conducted an unannounced visit to deliver the findings of the investigation. LPAs met with Administrator, Aaron Coronel.

On 3/27/2023, the Department received a complaint alleging that a resident (R1) sustained an injury on foot caused by staff in the facility. R1 was observed to be seen with bruising on left foot and left leg and laceration on the bottom of the toes. On 3/29/2023, the Department conducted an initial investigation visit and obtained copies of documents requested from the facility.

Continuation on LIC 9099-D, Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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-20230327135941

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: EBADAT RESIDENTIAL CARE HOME #3	FACILITY NUMBER: 435202380
	VISIT DATE: 10/04/2023

NARRATIVE

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Page 2 of 3.

Based on record review of facility’s Progress Notes on R1, S1 observed bruises on R1’s arms after a home health therapist gave R1 a massage on 3/16/2023. According to S1, they observed bruises on R1’s arms, hands, and legs from 3/16/2023 through 3/26/2023 however there was no documentation about informing R1’s doctor, responsible party or home health agency overseeing R1.

Based on investigation, R1 was also under home health services from 3/15/2023 through 3/26/2023. Based on interview with 6 home health agency clinicians, skin checks were conducted each visit and there were no observation of bruises or other types of lacerations on R1’s body and stated they did not observe any bruises on R1’s arms or legs. 4 out of 6 clinicians stated the facility staff did not inform them about R1 bruising easily.

Per interview with R1’s physical therapist (PTA), PTA did follow up visit on 3/24/2023 and stated R1 did not have a massage since it was not part of the care plan and focused on stretches and R1 did not want to sit up and PTA did not observe any bruises on R1’s arms or legs. Per interview with R1’s occupational therapist (OT), OT assisted R1 to walk in the bedroom, dining room, bathroom and hallway and did not observe any bruises on R1’s legs and did not observe anything concerning. Based on record review, OT visited R1 in the facility on 3/17/2023, 3/21/2023, and 3/24/2023.

Based on Appraisal/Needs and Services Plan 5/18/2022, R1 had a fall accident on 8/11/2020 which caused R1 to have surgery. R1 needs full assistance to do Activities of Daily Living (ADL). R1 walks slowly using a walker for mobility and needs assistance for direction. R1 needs 1:1 staff to assist all the time, such as assistance with toileting and walking around the facility. R1 will have daily walking exercise with the 1:1 staff.
On 3/26/2023 through 04/01/2023, R1 was admitted to the hospital due to condition unrelated to the injuries. The facility administrator informed the hospital doctor that R1 was ambulatory before R1’s surgery 3 weeks prior and since the surgery, the facility staff have been attempting R1 to ambulate with walker. Facility administrator stated “due to ambulation trails with the caregivers and R1 stepped on something” regarding the bruising on R1’s left foot and cut to posterior foot.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20230327135941

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: EBADAT RESIDENTIAL CARE HOME #3	FACILITY NUMBER: 435202380
	VISIT DATE: 10/04/2023

NARRATIVE

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Page 3 of 3.

During hospital admission, R1 was seen by a podiatrist, per MD, the foot injury “does not seem like a twisting injury or inversion of the foot…but because [the resident] is so osteopenic, it could be something simple as direct pressure on the foot from walking or stepping hard”.

Based on record review of R1’s Physician’s Report 6/17/2021, under Capacity for Self-Care, document states that R1 is not able to care for all personal needs and is able to ambulate without assistance.

On 5/3/2023, the Department interviewed 3 facility staff (S1 to S3). 3 out 3 staff stated R1 bruised easily, the staff would encourage R1 to walk with supervision and R1 could have sustained a cut during home health visits when R1 would walk with the clinicians. Per S1, R1 gets bruises by bumping into R1’s wheelchair, table or even by just crossing legs” and R1 would prevent bruising by moving R1 slowly and gently since “even with a light touch, R1 will still bruise”. Based on record review of progress notes, it was not documented between 3/16/2022-3/26/2023 if R1 bumped into objects causing the bruises to form.

On 6/7/2023, the Department interviewed R1’s primary care physician (PCP), PCP stated R1 would develop bruises through regular trauma, such as bumping into objects or getting hit by something, like how bruises typically occur in ordinary individuals. PCP did not believe R1 would bruise from only “crossing his legs” or by stretches from physical therapy or by being held onto during transfers.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator, Aaron Coronel and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

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