435202503-6-18-2021-26-AS-RMAO-C4NPSN-20210706113437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202503
Report Date: 06/17/2021
Date Signed: 06/18/2021 08:54:20 AM

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
11/17/2020 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20201117150224

FACILITY NAME:	HEALTHY LIVING RESIDENTIAL CARE HOME		FACILITY NUMBER:	435202503
ADMINISTRATOR:	MADELINE TAM CHOW		FACILITY TYPE:	740
ADDRESS:	251 DELIA STREET		TELEPHONE:	(408) 493-6955
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	6	CENSUS: 4	DATE:	06/17/2021
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Randel Chow, Administrator(ADM)		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility does not provide adequate food service to resident.
Facility does not provide proper laundry service for the resident.
Facility has bed bugs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted a complaint tele-visit today to deliver investigation findings. Due to COVID-19 preventive measures, facility visits have been suspended.

On 11/17/2020, the Department received a complaint with the above allegations against the facility. On 11/24/2020, an initial complaint investigation visit was conducted. During investigation, the resident and staff rosters, facility mitigation plan, the facility email log with Institute on Aging (IOA), food menu, residents' Appraisal/Needs Services Plan, and physician reports were obtained.

Continued, see LIC 9099-C, page 2 of 4.

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: 01/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2021

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-20201117150224

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: HEALTHY LIVING RESIDENTIAL CARE HOME	FACILITY NUMBER: 435202503
	VISIT DATE: 06/17/2021

NARRATIVE

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Facility does not provide adequate food service to resident:

On 01/11/2021, LPA interviewed Administrator (ADM). ADM stated on 10/2020 resident (R1) was served a burnt food during dinner cooked by ADM. ADM does not remember the food served to R1. R1 asked staff to replaced food. ADM remembered that instead of cooking, they ordered fast food for R1. During LPAs inspection of the facility food supply, the facility 2 days perishable and 7 days non-perishables foods are inspected.

On 01/11/2021, LPA interviewed 4 residents (R2 - R5), and all of them stated they do not have any complaint about the facility food service. Also, on the same day, LPA interviewed staff (S1 and S2). S1 and S2 stated they never heard any resident complained about the facility food service.

On 01/15/2021, LPA interviewed staff (S3), S3 stated never heard any of their residents complained about the facility food.

On 01/22/2021, R1 was interviewed. R1 could not remember any issues about food service on 10/2020.

Facility does not provide proper laundry service for the resident:

On 01/11/2020, LPA interviewed ADM. ADM stated that resident's R1's family member about his/her concerns of how facility handles R1's laundry. R1's jean pants was discolored. ADM stated the facility did not use bleach to wash R1's clothes. ADM stated R1's family member was informed the possible reasons for R1's jean's discoloration was due to frequent wash. ADM stated the family member was satisfied with the explanation provided to R1's family member. ADM does the facility/residents' laundry.

Continued, see LIC 9099-C, page 3 of 4

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20201117150224

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: HEALTHY LIVING RESIDENTIAL CARE HOME	FACILITY NUMBER: 435202503
	VISIT DATE: 06/17/2021

NARRATIVE

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On 1/11/2020, LPA interviewed 4 residents (R2 - R5), all residents stated they do not have any complaint about the facility laundry service. On the same day, LPA interviewed staff (S1 and S2). S1 and S2 stated they do not do laundry because ADM does it. They also stated that they never heard any resident complained about the facility laundry service.

01/15/2021, LPA interviewed staff (S3), S3 state never heard any resident complained about the facility laundry service, and ADM does the laundry in the facility.

On 01/22/2021, LPA interviewed R1. R1 stated cannot remember any issue about the laundry service when R1 was at the facility.

Facility has bed bugs:

On 01/11/2021, LPA interviewed ADM. ADM stated that sometime in 2020, the facility staff found bed bugs in the facility. ADM stated facility hired an exterminator on 8/19/2020 to eradicate the presence of bedbugs. ADM stated there were no presence of bedbugs after 08/19/2020 treatment. During investigation, LPA obtained a copy of exterminator's report.

Based on the review of exterminator's report, the presence of bedbugs have been eradicated.

ADM stated that resident (R1) complained about having bumps on arms and body on November 2020. ADM stated that R1 had bumps on arms and body but could not confirmed if it was from a bedbugs bites. ADM stated that R1's family member moved R1 to another facility. ADM stated that R1's family member informed ADM that R1 was admitted to the hospital prior to moving to the new care home wherein they found bites on R1's arm.

ADM stated that R1 had a rash on arms but not convinced that they were from a bedbugs bite when R1 moved out in 11/2020 from the facility.

Continued, see LIC 9099-C, page 4 of 4

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20201117150224

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: HEALTHY LIVING RESIDENTIAL CARE HOME	FACILITY NUMBER: 435202503
	VISIT DATE: 06/17/2021

NARRATIVE

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On 01/11/2021, LPA interviewed 4 residents (R2 - R5), 3 of 4 residents stated they did not observed bed bug in the facility while R5 was not able to provide information.

On 01/11/2021, LPA interviewed 2 staff (S1 - S2). Both of them stated did not know about bed bug issues in the facility.

On 01/15/2020, LPA interviewed staff (S3). S3 stated S3 was aware of bed bug issue in the mid-2020. But S3 stated S3 does not hear any resident complained about the bed bug after facility hired a company to do the pest control for the facility.

On 1/22/2021, LPA interviewed R1. R1 stated R1 cannot remember any bed bug issue when R1 was at the facility.

The department has investigated the above allegations. Based on the investigation, observations, records reviewed, and interviews conducted, the Department found that the
above allegations are 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 allegations did or did not occur.

No deficiencies or citations noted at today’s complaint investigation visit. Exit interview conducted with Administrator. A copy of this report was provided for signature.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

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