435202503-6-18-2021-26-AS-RMAO-C6NN88-20210908101355

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202503
Report Date: 06/17/2021
Date Signed: 06/18/2021 09:51:41 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
02/10/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20210210133723

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:	DATE:	06/17/2021
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Randel Chow		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident is left on soiled diaper.

INVESTIGATION FINDINGS:

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

On 02/10/2021, the Department received a complaint about the above allegation against the facility. An initial complaint investigation visit was conducted on 02/18/2021, S1 - S3 and ADM were interviewed. R1's Admission agreement and the termination letter were obtained . On 03/11/2021, LPA interviewed residents R2 - R4.

Continued, see LIC 9099-C.

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: 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

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-20210210133723

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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Resident is left on soiled diaper:
On 2/18/2021, LPA interviewed ADM. ADM stated R1 needs a diaper change about 10 times per day. ADM stated R1 had an aggressive behavior when R1 had soiled diaper. ADM stated R1 needs help to go to restroom, and needs help to change diaper due to R1 has paralysis at left side.

LPA interviewed staff (S1 - S3), all of them stated R1 requires diaper changing more than 8 times per day. 3 out of 3 staff stated residents (R2 - R4) require diaper change 1 or 2 times per day. All 3 staff stated that they checked R1's diapers many times every day. All 3 staff stated R1's behavior of changing diaper many time per day is unusual,

R1 moved out from the facility before the investigation was conducted. LPA was not able to interview R1 for the above allegation. On 3/11/2021, LPA interviewed residents (R2 - R4). All 3 residents stated the facility staff check residents' diapers every two hours and facility staff change the diaper if needed. All 3 residents stated they do not have problems for diaper change.

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

No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with Administrator. Due to technical issue, a copy of this report was provided via email 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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