435202503-10-17-2023-26-AS-KHOS-CXAURL-20231105144853

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202503
Report Date: 10/17/2023
Date Signed: 10/17/2023 05:11:25 PM

Unsubstantiated

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
03/01/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220301165404

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:	0	CENSUS: 0	DATE:	10/17/2023
		UNANNOUNCED	TIME BEGAN:	10:39 AM
MET WITH:	Randel Chow		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Residents are not being allowed to talk anyone.
Insufficient caregiving assistance to residents are not being met.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Steve Chang and Manuel Monter conducted a complaint investigation visit to deliver investigation finding today. LPA met with Administrator Randel Chow (RC).

On March 4, 2022, an initial investigation visit was conducted wherein LPA met and interviewed the Ms. Xiuyan Chen (S1), 2 staff, and 5 residents. LPA also obtained residents/staff roster and resident facility documents such as Residents/staff roster and resident medical documents.

Continue on LIC9099-C. Page 1 of 3.

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: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

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 5

Control Number 26-AS-20220301165404

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: 10/17/2023

NARRATIVE

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Residents are not being allowed to talk anyone:
On March 24, 2022, LPA conducted an interview with the S1 who stated could not remember the date and time, but S1 remember when resident R1 asked him/her if R1 can open the door for a visitor while he/she was in the shower. S1 told R1 to open the door for the visitor which happened to be employees from the Santa Clara County.

On February 15, 2022, the Santa Clara County staff visited the facility wherein no one answered the main door for about 5 minutes. It was R1 who opened the door. R1 informed Santa Clara County staff that he/she was not allowed to talk to anyone because it was the house rule of the facility.

On May 24, 2023, the Department conducted a follow-up phone interview with S1. S1 stated that he/she was in the bathroom taking a shower when R1 informed him/her that someone was at door wherein he/she instructed R1 to open the door for the visitor. S1 stated that he/she came out of the shower quickly wherein he/she met with the Santa Clara County employees.

S1 denied allegation that he/she told R1 not to talk to anyone, nor he/she restricted other residents not to speak to anyone at the facility. S1 stated, “I do not know why he/she said that he/she is not allowed to talk to anyone.”

On May 25, 2023, the Department conducted an interview with the Licensee Chow (MC). MC stated that S1 took over the facility in October 2021. MC stated after he/she sold the "business” (RCFE- Healthy Living). MC stated he/she did not have access to the facility, nor he/she was not allowed in the facility; therefore, he/she does have any knowledge about S1 restricting residents not to speak to anyone.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
03/01/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220301165404

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:	0	CENSUS: 0	DATE:	10/17/2023
		UNANNOUNCED	TIME BEGAN:	10:39 AM
MET WITH:	Randel Chow		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident did not consent to take antipsychotic medication.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Steve Chang and Manuel Monter conducted a complaint investigation visit to deliver investigation finding today. LPA met with Administrator Randel Chow (RC).

On March 4, 2022, an initial investigation visit was conducted wherein LPA met and interviewed Ms. Chen (S1), 2 staff, and 5 residents. LPA also obtained residents/staff roster and resident facility documents such as Residents/staff roster and resident medical documents.

Continue on LIC9099-C. Page 1 of 2.

Unfounded

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: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20220301165404

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: 10/17/2023

NARRATIVE

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Resident did not consent to take antipsychotic medication:

On March 4, 2022, LPA conducted an interview with Ms. Chen (S1) who stated that resident R1 did not refused to take his/her prescription medications. S1 stated that R1 regularly takes his/her prescribed medication including over the counter (OTC) medications.

On May 24, 2023, the Department conducted a follow-up phone interview with S1. S1 stated that when he/she took over the facility in October 2021, R1 has already been prescribed medication for depression and anxiety which was discontinued in August either 2021 or 2022 by his/her MD. S1 stated that R1 was prescribed medication for neurocognitive disorder aside from his/her other medications such as for hypertension, cholesterol and other 3 OTC supplements.

On May 25, 2023, the Department conducted an interview with Licensee, Madeline Chow (MC). MC stated that prior to R1’s placement to the facility on July 31, 2021, R1 was already on a prescribed medication to control R1’s Behavioral Aggression and Neurocognitive disorder while admitted at the hospital.

Based on review of R1’s medication list, in July 2021, R1 was taking 4 medications. 1 Out of 4 medications was to control R1’s aggressive behavior by a medical professional at the hospital. R1 did not have any relatives or representative to consent for himself/herself during his/her hospitalization.

The Department has investigated the above allegation. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations cited under California Code of Regulations Title 22. Exit interview conducted with MC. The report was provided to MC for signature. A copy of the report was provided to MC.

Page 2 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20220301165404

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: 10/17/2023

NARRATIVE

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Insufficient caregiving assistance to residents are not being met:
On March 4, 2022, the Department interviewed Ms. Xiuyan Chen (S1). S1 stated he/she had 3 staff including himself/herself who provided care and supervision to residents. S1 also stated that he/she resides at the facility. S1 stated that he/she was looking into hiring additional staff.

On May 24, 2023, the Department conducted a follow-up interview with S1. S1 stated when Santa Clara County employees visited the facility on February 15 2022, S1 was the only staff present at the facility and no one else was scheduled to work at the facility. S1 stated that the facility has 2 staff who worked 2-3 days a week aside from S1. S1 stated, “I was trying my best to find caregiver. It was very difficult because I was working at another care home and working at my clinic at the same time.”

On May 25, 2023, the Department conducted a phone interview with the Licensee Madeline Chow (MC). MC stated he/she no longer overseeing the facility since October 2021. MC stated that he/she used to have 5 staff including him/her, his/her spouse and 3 other staff. MC stated that when he/she was managing the facility, there were no issues with staffing. MC stated that they were meeting the needs of residents until October 2021. MC stated that he/she did not know how many staff were working for S1 after October 2021. MC stated that retained his/her former 2 staff. MC stated that ADM informed him/her that S1 would remove R1 from resident’s roster because R1 will be designated staff.

Based on review of the facility staff roster, the document showed S1 and two staff (S2, S3) worked for the facility to provide care and supervision to resident, which included responsibilities but not limited to cleaning the facility and cooking resident meals 3 times a day.

The Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

No citations noted at today’s compliant investigation visit. Exit interview conducted with Licensee. A copy of this report was provided to Licensee.

Page 3 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5