435202414-11-30-2020-26-AS-KHOS-BVWT2D-20201202132027

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202414
Report Date: 09/10/2020
Date Signed: 11/30/2020 02:50:25 PM

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
07/08/2020 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200708152707

FACILITY NAME:	DURALIZA CARE HOME		FACILITY NUMBER:	435202414
ADMINISTRATOR:	AIDA D. PENDON		FACILITY TYPE:	740
ADDRESS:	1938 ENSIGN WAY		TELEPHONE:	(408) 923-1160
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95133
CAPACITY:	6	CENSUS: 6	DATE:	09/10/2020
		UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Rhonald Aranzaso		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

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Facility staff are not assisting resident with walking.
Facility staff are not following resident's physical therapy care plan.
Resident is not allowed to leave their room.
Resident is not allowed access to a telephone.
Resident is not allowed to participate in activities.
Facility staff are not providing resident an adequate quantity of food.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gladys Kuizon conducted a subsequent complaint tele-visit today to deliver investigation findings. Due to COVID-19 preventive measures, facility visits have been suspended. LPA met with facility designee, Rhonald Aranzaso. Also present during meeting were LPAs Steve Chang, Grace Davis and Steve Nguyen.

On July 8, 2020, the Department received the above allegations against this facility. Reporting party (RP) alleged that resident (R1) was being neglected by facility staff. LPA interviewed RP on July 9, 2020.

On July 14, 2020, LPA conducted an unannounced initial complaint investigation tele-visit and interviewed facility administrator (ADM). Facility records were requested.

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

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2020

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-20200708152707

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: DURALIZA CARE HOME	FACILITY NUMBER: 435202414
	VISIT DATE: 09/10/2020

NARRATIVE

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From July 9, 2020 to August 11, 2020, LPA conducted interviews. LPA interviewed 6 staff members and met with 6 residents.

Based on interviews, 6 out of 6 staff members stated that R1 is being assisted by staff with meals, medications, activities of daily living including walking and exercising, and is encouraged to join activities and socialize with other residents. 6 out of 6 staff stated that R1 is able to communicate and express R1's preferences and they do not force R1 when R1 refuses to exercise, walk or join an activity.

Administrator and all staff stated that in April 2020, R1 was placed in a 14-day isolation period with a one-on-one caregiver due to COVID-19 precautions and under the guidance of Santa Clara County Health Department and San Andreas Regional Center. Records showed that R1 was cleared from isolation and was allowed to mingle with other residents and staff as of April 24, 2020. During isolation period, R1 was only able to leave R1's bedroom for walks outside the facility. R1 was provided activities by R1's day program through an iPad and R1 was taught how to access the day program activity and can log in when R1 wants to.

Due to developmental disabilities, LPA was unable to obtain relevant responses from 4 out of 6 residents. 2 residents (R1 & R2) confirmed that R1 is able and allowed to go out of R1's room and mingle with other residents. R2 stated that R1 goes out of R1's room to play bingo with R2.

On July 21, 2020, LPA interviewed R1. R1 stated that R1 can go out of R1's room and occasionally plays cards and bingo with resident, R2, in the activity area. R1 also stated that R1 draws and colors in the activity area. R1 confirmed that R1 has a one-on-one caregiver and staff assists R1 with walking. R1 stated that R1 does not like to walk too much due to R1's balance and risk of seizures. R1 stated staff will assist R1 if R1 wants to exercise and walk. R1 stated that all staff treats R1 well except staff, S1. According to R1, S1 gives R1 a certain look all the time and when S1 assists R1, S1 hands R1 things in a harsh manner. R1 confirmed that staff assists R1 with medications and R1 has no complaints about food in the facility. R1 stated staff gives R1 food choices and R1 can ask for more food if R1 wants to. R1 also confirmed that R1 can use the telephone anytime and R1 regularly receives calls from friends and social workers.

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

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20200708152707

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: DURALIZA CARE HOME	FACILITY NUMBER: 435202414
	VISIT DATE: 09/10/2020

NARRATIVE

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On August 19, 2020, LPA met with R1 and R1's social worker. R1 confirmed statements on August 11, 2020 interview, with the exception of naming a different staff member, S2, who R1 alleges was not friendly to R1 and ignores R1 when R1 greets S2. R1 confirmed that S2 assists R1 with R1's iPad and phone. R1 also stated that R1 is afraid of staff, S3, due to S3 having a loud voice. R1 stated S3 had done nothing bad to R1 and S3 did not hurt or yell at R1.

On August 11, 2020 at 3:13 PM and August 19, 2020 at 1:30 PM, LPA conducted unannounced facility tele-visits. On both occasions, R1 was observed with a one-on-one caregiver in R1's room. R1's bedroom door was observed open and staff were going in and out of R1's bedroom without restrictions. R1 confirmed that R1 can go out and mingle with other residents in the living room but R1 prefers to stay in R1's room at the time.

Interviews and records revealed that R1 has no active orders for physical therapy. R1 was provided home health physical therapy visits from April 19, 2020 to May 27, 2020. No new orders were prescribed.

This Department has investigated these allegations. Based on interviews conducted, records reviewed and LPA's observation, the Department has found that these allegations are UNFOUNDED, meaning that the allegations are false, could not have happened and/or is without a reasonable basis.

No deficiency was cited. A copy of this report was sent to Rhonald Aranzaso for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2020

LIC9099 (FAS) - (06/04)

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