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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202415
Report Date: 02/19/2025
Date Signed: 02/19/2025 11:52:16 AM

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
03/24/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220324131206
FACILITY NAME:CASA ALICE CARE HOMEFACILITY NUMBER:
435202415
ADMINISTRATOR:PING JING ZHAOFACILITY TYPE:
740
ADDRESS:809 ALICE AVENUETELEPHONE:
(650) 279-7488
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94040
CAPACITY:6CENSUS: 6DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Carmen DuranTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility is neglecting resident by not caring for resident's foot
INVESTIGATION FINDINGS:
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On 2/19/2025 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit at the facility. LPA met with Care Staff Carmen Duran and explained the purpose of the visit.

Regarding the allegation of Facility is neglecting resident by not caring for resident's foot, according to RP client's (R1) foot is dark purple. RP believes the staff workers are causing R1s foot to deteriorate by not taking R1 out to walk. RP believes staff should be taking the client for walks/exercising it. By not moving the foot (blood circulation) and keeping it elevated is worsening the condition of the foot. RP states he/she is not certain if the facility is following through with physical therapy for the client.

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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 26-AS-20220324131206
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: CASA ALICE CARE HOME
FACILITY NUMBER: 435202415
VISIT DATE: 02/19/2025
NARRATIVE
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LPA Kabariti interviewed 2 staff members. S1 states that R1 is always sitting in the chair and they cannot stop R1 from doing what he/she wants. They encourage R1 to elevate his/her leg while sitting on the chair throughout the day, but R1 does not listen, but R1 is good at elevating his/her leg while sleeping. The doctor knows about R1s foot and encourages R1 to elevate his/her legs but never does that. S2 is one of the main people who takes care of R1. S2 states that they encourage R1 to elevate his/her foot while sitting on the chair everyday and throughout the day but R1 doesn't listen. S2 encourages walks around the house but needs a 2-person assist because R1 is of risk of falling. R1 takes a really long time to take a few steps. From the living room to R1s room it can take 45 minutes but staff are always there to watch and assist. The doctor encourages to elevate R1s foot and do physical therapy.

According to records review, part of the reappraisal of the resident dated before the complaint was filed, it is stated that R1s feet are more swollen and staff encourage R1 to keep feet up as much as possible. R1s ambulation will be addressed by providing two people lifting with transfers and ensure that R1 is safe due to fall risk being high. Based on visitation logs provided by the facility, there was a scheduled physical therapist doing visits to R1.

Based on interviews & 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 cited today. Report is reviewed and copy is provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
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