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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202509
Report Date: 10/30/2024
Date Signed: 10/30/2024 11:10:05 AM

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
08/17/2021 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210817095116
FACILITY NAME:VILA MONTEFACILITY NUMBER:
435202509
ADMINISTRATOR:DONALD WINDHAMFACILITY TYPE:
740
ADDRESS:17090 PEAK AVENUETELEPHONE:
(408) 500-2693
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:28CENSUS: 25DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Nicholas InnehTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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9
Staff did not notify Resident Representative of resident's change in health insurance carrier.
Facility is not assisting resident with medical care.
INVESTIGATION FINDINGS:
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13
On 10/30/2024, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Nicholas Inneh and LPA explained the purpose of the visit.

Regarding the allegation of Staff did not notify Resident Representative of resident's change in health insurance carrier and facility is not assisting resident with medical care, reporting party (RP) stated that when resident (R1) turned 65, RP signed R1 up for Medicare and had also signed up for Santa Clara Family Health Plan. Without informing RP, Director (S1) signed R1 up for another insurance provider (Anthem). RP had no idea until he/she received a letter from Santa Clara Family Health Plan stating that R1 was "cut off". RP discovered that S1 had signed R1 for Anthem in April of 2021, without consulting RP. After RP found out, RP signed R1 up again with Santa Clara Health Plan and S1 got upset with RP and is now refusing to help with getting R1 medical treatments, setting up and take R1 to doctor's appointments.

page 1 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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-20210817095116
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: VILA MONTE
FACILITY NUMBER: 435202509
VISIT DATE: 10/30/2024
NARRATIVE
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LPA Ng interviewed RP and confirmed the story that was provided on the initial complaint. LPA was able to interview S1 and it was stated that the facility used a different insurance, an in-house medical insurance provider. RP stated R1's insurance got changed without any apparent reason. S1 tried to fix it, and later found that a family member (F1) changed the insurance without notifying S1 and the staff. F1 somehow told S1 that he/she wanted to use some other insurance. S1 explained to F1 that if he/she used some other insurance, then R1 could not use the insurance, that sent physician and nurse to the facility. If R1 used other insurance, then R1 had to travel to clinic or hospital to receive medical assistance. It would not be ideal since R1 was in wheelchair, that R1 might have to travel by taxi to see the doctor. That was why S1 tried to persuade F1 to use the insurance instead. There was no lapse that R1 did not have a time that there was no insurance to receive medical assistance.

LPA Ng also interviewed three residents. Two out of three (R2 & R3) mentioned that they had no problem with insurance that it was not changed. R1 stated he/she was not aware that the insurance was changed or his/her representative not being notified.

For the residents medical care, R1 stated he/she saw the doctor recently but did not have any note from the doctor. R2 stated he/she got assisted getting medical care from the facility. R3 stated he/she had his medical visit about 2 weeks ago and also got medicine prescribed. A staff member (S2) was also interviewed and stated that if a resident did not have insurance, the facility would help that resident to find one. So no insurance, no issue. S2 also shared that he/she was not aware of any resident not being assisted in the facility because of insurance or any other kind of problem.

Based on interviews, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.

page 2 of 2

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
08/17/2021 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210817095116

FACILITY NAME:VILA MONTEFACILITY NUMBER:
435202509
ADMINISTRATOR:DONALD WINDHAMFACILITY TYPE:
740
ADDRESS:17090 PEAK AVENUETELEPHONE:
(408) 500-2693
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:28CENSUS: 25DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Nicholas InnehTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is mismanaging resident's funds.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/30/2024, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Nicholas Inneh and LPA explained the purpose of the visit.

Regarding the allegation of facility is mismanaging resident's funds, RP stated that he/she sends $39/month to the facility for R1s allowance, and R1 says he/she never gets it.

LPA Ng was able to interview three residents. R1 stated that he used to get money from S1 to spend. R1 showed LPA a card stating that he/she used the card to buy things. R2 stated he/she got the money from VA. VA deposited the money into a checking account and R2 could draw the money out. R3 stated he/she had a finance coordinator. S1 gives money to spend whenever R3 asked for it.

page 1 of 2
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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 4
Control Number 26-AS-20210817095116
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: VILA MONTE
FACILITY NUMBER: 435202509
VISIT DATE: 10/30/2024
NARRATIVE
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When S1 was interviewed, S1 stated he/she had every residents' money including R1's money in his possession. S1 mentioned that F1 stopped sending money to R1 recently. R1 currently used the Life Freedom Card that was managed by BMC (Benefits Management Corporation) to buy the things R1 needed.

According to the LIC 405 (Record of Client’s/Resident’s Safeguarded Resources) for R1, the logs shows that from 10/9/2017 to 1/11/2019, R1 was receiving $100. Starting from 2/14/2019 to 7/20/2021, different amounts have been received ranging from $37-$161. This was also audited by LPA Ng and it didn’t have any discrepancy. The document also shows how much money was given to R1 upon request and countersigned by S1 and R1.

Based on interviews & records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is reviewed and copy is provided.

page 2 of 2
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4