435202503-10-17-2023-26-AS-RMAO-CXTVJL-20231122152854

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202503
Report Date: 05/24/2023
Date Signed: 10/17/2023 05:00:26 PM

Substantiated

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
01/20/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220120131050

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:	05/24/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Randel Chow		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff is sleeping in resident's room.
Staff instructs resident to provide care for other residents.
Staff instructs resident to work at the facility.
Resident sustained injury.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Steve Chang and Manuel Monter conducted a complaint investigation visit to deliver investigation findings and met with Administrator of the facility Healthy Living Randel Chow (RC).

On Janurary 20, 2022, the Department received a complaint with the above 4 allegations.

On Janurary 25, 2022, Initial investigation visit was conducted. Xiuyan Chen (S1) was interviewed. Residents/staff roster and resident documents were obtained.

Continue on LIC9099-C. page 1 of 3.

Substantiated

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-20220120131050

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: 05/24/2023

NARRATIVE

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Staff slept at resident's room:
The Department conducted inspection/investigation visits at the facility on the following dates January 25, 2022, February 10, 2022, and April 29, 2022.

On January 25, 2022, and February 10, 2022, LPA toured the facility and found a queen size bed in resident room 2. S1 stated that resident R1 was his/her significant other. S1 confirmed he/she shared a bedroom with R1 since they are in an intimate relationship, which occurred when S1 moved into the facility sometime in October.

Staff instructs resident to provide care for other residents/ Staff instructs resident to work at the facility/ Resident sustained injury.

On January 25, 2022, LPA interviewed S1. S1 stated he/she thinks its good for R1 to work at the facility. S1 stated he/she let R1 do some work for the facility. S1 stated R1 moved things and had a minor back pain.

S1 stated, in response to the allegations in an email dated February 2, 2022, R1 did assists in washing his dishes. S1 also stated R1 “had a little skin scratch on his left arm…after he/she helped to cleaned backyard.”

During an interview on January 25, S1 stated that he/she allows R1 to leave the facility unassisted with another resident for a daily walk. A review of R1 Physicians report dated July 31, 2021 states R1 cannot leave the facility unassisted.

On May 25, 2023, the Department conducted a phone interview with licensee (S2). S2 stated that sometime in January 2022, S2 heard that S1 and R1 were in a relationship. S2 was informed R1 was working at the facility.

Based on R1's physicians report dated July 31, 2021, R1 requires stand by assistance with walking. R1 mental condition is categorized as confused/disoriented. The physicians report also states R1 requires supervision.

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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

Control Number 26-AS-20220120131050

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: 05/24/2023

NARRATIVE

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Based on a review of R1's neuro-assessment, R1 was evaluated with a major Neurocognitive disorder.

Based on observations, records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with RC. A copy of this report was provided to RC. Appeal Rights was provided.

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: 3 of 5

Control Number 26-AS-20220120131050

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/18/2023 Section Cited CCR 87405(c)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties. (c) Failure to comply with all licensing requirements pertaining to certified administrators may constitute cause for revocation of the license of the facility. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated he/she will submit a written statement understanding of his/her responsiblities as Administrator.
	8 9 10 11 12 13 14	Based on investigation and interviews conducted, R1, who is a resident, was allowed to work at the facility which poses an immediate health, safety and personal rights of risk to a persons in care.	8 9 10 11 12 13 14
Type B 10/24/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.	1 2 3 4 5 6 7	Licensee agreed to submit a plan of correction by the due date and understood that the facility staff shall provide care and supervision to residents and to prevent resident to obtain injuries.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on the interviews and documents reviewed; ADM was not aware that Staff at the facility allowed R1 to work the facility unsupervised. Wherein R1 sustained an injury.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

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 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-20220120131050

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/18/2023 Section Cited CCR 87355(e)(1)	1 2 3 4 5 6 7	87355 Criminal Record Clearance (e) (1) Obtain a California clearance or a criminal record exemption as required by the Department	1 2 3 4 5 6 7	Licensee agreed and understood that R1 was not allowed to work at the facility. Licensee to submit a written and signed statement that facility staff need to associate with the facility by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review and interviews, R1 worked at the facility without fingerprint clearance between October 2021 and March 15, 2022 which poses an immediate health, safety risk to a person in care.	8 9 10 11 12 13 14
Type B CCR	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	8 9 10 11 12 13 14		8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5