435202430-6-26-2024-26-AS-RMAO-D72V78-20240710161041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202430
Report Date: 06/26/2024
Date Signed: 06/26/2024 04:40:25 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

COMPLAINT CONTROL NUMBER: 26-AS-20230327143155

FACILITY NAME:	LIFE SERVICES ALTERNATIVES INC		FACILITY NUMBER:	435202430
ADMINISTRATOR:	GOSS, SHELLY		FACILITY TYPE:	735
ADDRESS:	3121 HUMBOLT AVE		TELEPHONE:	(408) 418-3667
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	6	CENSUS: 6	DATE:	06/26/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Administrator, Shelly Goss		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff verbally abuse resident while providing care
Staff not assisting resident during bowel movement
Staff serving uncooked food to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator and stated the purpose of today’s visit.

On 3/27/2023, the Department received a complaint with the above allegations. On 4/3/2023, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

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 4

Control Number 26-AS-20230327143155

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: LIFE SERVICES ALTERNATIVES INC	FACILITY NUMBER: 435202430
	VISIT DATE: 06/26/2024

NARRATIVE

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Page 2 of 4.
Staff verbally abuse resident while providing care.
It was alleged that staff (S1) was verbally abusive and mean to residents at the facility.

On 4/6/2023, the Department interviewed 3 staff (S1-S3) during the visit. 3 Out of 3 staff stated they have not seen a staff member yell at a resident, say bad words to a resident or be mean towards a resident. 3 Out of 3 staff stated they are aware of resident’s personal rights and they have been trained in ensuring residents are not physically or verbally abused in the facility.

Based on record review, LPA Rai reviewed S1-S3 staff file and observed 3 out of 3 staff had received training on resident's personal rights and signed SOC 341A Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders.

On 4/6/2023, the Department interviewed 2 out of 5 (R1-R2) residents at the facility. 3 Out of 5 residents were not able to communicate or refused to be interviewed during the visit. R1 stated he/she feels safe at the facility and has not seen or heard of staff being verbally abusive towards the resident by not being “hostile/mean” or “aggressive/pushy”. R2 stated S1 is mean toward R2 but cannot specify incidents or events of how S1 is mean towards R2.

Staff not assisting resident during bowel movement.
It was alleged that staff (S1) did not assist residents during a bowel movement.

On 4/6/2023, the Department interviewed 3 staff during the visit. 3 Out of 3 staff stated the facility administrator has trained the staff on providing continence care to the residents and they stated the staff will respond quickly to when residents require help. 2 Out of 3 resident stated they have not seen a resident being ignored when they call for help. S2 stated staff have ignored resident’s calling for the staff, but the staff were preparing lunch, dinner or snacks for residents. S2 could not clarify if the staff were ignoring the resident on purpose or resident was calling for food and the staff were preparing the food for the resident. The staff stated only 1 out of 5 residents will verbally communicate for assistance during bowel movement and 3 out of 5 residents do not need assistance during bowel movement but can verbally ask for help when needed. 1 out of 5 resident is limited in verbal cues therefore the staff will assist resident every 2 hours.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20230327143155

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: LIFE SERVICES ALTERNATIVES INC	FACILITY NUMBER: 435202430
	VISIT DATE: 06/26/2024

NARRATIVE

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Page 3 of 4.

On 4/6/2023, the Department interviewed 2 out of 5 (R1-R2) residents at the facility. 3 Out of 5 residents were not able to communicate or refused to be interviewed during the visit. R1 stated the staff will help a lot if residents need help after a bowel movement, but the resident will “wait a couple of minutes but they will come right away”. R2 stated S1 will tell R2 to “hurry up” but R2 isn’t able to pull up the pants after using the toilet due to health problems. R2 was not able to state when this incident occurred and R2 did not state other incidents where S1 did not assist the residents during bowel movement.

Based on random record review of 3 resident's Physician's Report, 2 out of 3 residents are able to care of his/her own toilet needs. 1 Out of 3 residents is not able to care for his/her own toilet needs.
Based on random record review of 3 resident's Appraisal/Needs and Services Plan, 2 out of 3 residents need verbal prompts to complete the majority of ADLs(Activity of Daily Living). 1 Out of 3 residents needs two person assist for toileting needs. Staff is instructed to monitor and record bowel movement daily.
Based on random record review of 3 resident's Progress Notes of August 2022, 2 out of 3 residents did not have record of resident having an accident due to bowel needs were not met. 1 out of 3 residents had record of daily observation of bowel movements, including staff assisting resident at night for toileting needs but no record of resident having an accident due to bowel needs were not met.

Staff serving uncooked food to residents.
It was alleged staff (S1) was making residents eat cooked fish that was raw.

On 4/6/2023, the Department interviewed 3 staff during the visit. 3 Out of 3 staff stated they are trained in cooking the food for the residents and have received training by the facility administrator. 2 Out of 3 staff stated residents do have preferences and they will cook certain food items based on preferences as well. 3 Out of 3 staff stated they have not served uncooked food to the residents and have not make residents eat cooked fish that was raw. 3 Out of 3 staff could not stated an incident that occurred in the facility where the fish served to the residents which was raw.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20230327143155

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: LIFE SERVICES ALTERNATIVES INC	FACILITY NUMBER: 435202430
	VISIT DATE: 06/26/2024

NARRATIVE

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Page 4 of 4.

On 4/6/2023, the Department interviewed 2 out of 5 (R1-R2) residents at the facility. 3 Out of 5 residents were not able to communicate or refused to be interviewed during the visit. R1 stated the staff have not served raw food, such as uncooked fish. R1 stated he/she likes pizza and cheese and will request different food if R1 does not like to food served during meal service. R2 stated S1 cooked the fish and it looked slimy and the staff took the fish away from resident after R2 complained. R2 stated she was not sure to eat anything else so R2 requested to eat the fish. LPA Rai clarified with R2 if the staff forced R2 to eat the fish and R2 stated no.

On 6/26/2024, ADM stated staff was provided training on safe handling of food. LPA Rai reviewed staff training conducted on 4/14/2023 with registered dietitian on topic "Temperature Danger Zone" which included safe handling of food, such as fish and other seafood.

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 cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator (ADM) Shelly Goss and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

LIC9099 (FAS) - (06/04)

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