435202531-6-3-2020-26-AS-SYIP-BQNTB7-20200617143441

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202531
Report Date: 06/03/2020
Date Signed: 06/03/2020 11:09:25 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
01/09/2020 and conducted by Evaluator James G Santos

COMPLAINT CONTROL NUMBER: 26-AS-20200109155457

FACILITY NAME:	SAKURA GARDENS VILLA LLC		FACILITY NUMBER:	435202531
ADMINISTRATOR:	KITAMURA, HIRO		FACILITY TYPE:	740
ADDRESS:	531 N CENTRAL AVE		TELEPHONE:	(408) 379-4110
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	15	CENSUS: 12	DATE:	06/03/2020
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Hiro Kitamura		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident sustained injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) James Santos conducted an unannounced tele-visit today to deliver the investigation finding on the above allegation. Due to the current COVID-19 situation, LPA met with administrator, Hiro Kitamura via facetime.

On 1/16/2020, the initial investigation visit was conducted. During initial visit at around 3:00Pm, LPA obtained copies of resident's (R1) physician's report, needs and services plan, hospital discharge notes, VA nurse notes, progress notes, incident report and letters written by staff and residents' family members.

On 1/21/20, a subsequent visit was conducted. During visit at around 2:30pm, LPA conducted interviews with 3 staff and 4 residents which includes R1.

All 3 staff interviewed stated they do not know how R1 got the bruise. They also stated they have not seen R1 fall.

Continued on page 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2020

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 3

Control Number 26-AS-20200109155457

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: SAKURA GARDENS VILLA LLC	FACILITY NUMBER: 435202531
	VISIT DATE: 06/03/2020

NARRATIVE

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Two of the 3 staff interviewed stated R1 might have hit the arm rest of the wheelchair. Two out of the 4 residents interviewed stated that they are doing ok in the facility. They also stated that staff are ok and they are well treated by them. LPA was unable to conduct interviews with the other 2 residents which includes R1. R1 refused to talk and the other resident was unable to communicate.

On 1/29/20, a subsequent visit was conducted. During visit at around 11:00am, LPA conducted interviews with 2 additional staff. Both staff interviewed stated they do not know how R1 got the bruise. They both stated they do not think any of the staff will hurt their residents.

On 5/19/20, LPA spoke with R1's Responsible Party (RP) via telephone. Per interview, RP does not know what caused the bruising on R1. RP also stated that staff did not know the cause as well. Per RP, R1 was provided with good care in the facility and the staff are good.

On 5/22/20, LPA spoke with a fifth resident via telephone. Per interview, resident stated that staff in the facility are fine and resident has not seen any other residents fall in the facility.

On 5/27/20, LPA spoke with R1's Visiting VA nurse via telephone. Per interview, VA nurse was unable to tell the cause of the bruising. Per VA nurse, R1 likes to lean to the left side so it is possible that R1 may have hit the arm rest of the wheelchair. Per VA nurse, R1 also had low platelets which causes the body to be easily bruised. R1 was also taking a medication to prevent stroke which is also a blood thinner that can cause bleeding and bruising. VA nurse also stated the facility is one of the good facilities and would recommend it.

Per review of the incident report, on 1/1/20, staff noticed red botches on R1's left side of the body while changing clothes. Staff notified R1's RP and VA nurse. R1's RP and VA nurse came to see R1 on 1/2/20 and VA nurse recommended for R1 to be sent to hospital for check up. Per review of R1's progress notes, on 1/1/20 at around 3:30pm, staff noted light yellow and blue spot on R1's left side. Administrator was contacted. Staff noted no pain and vital was ok. On 1/2/20, VA nurse arrived at around 1:30pm and R1 was transported to the hospital at around 2:30pm.

Copies of Outside Agency forms were reviewed and noted on 1/2/20, VA nurse evaluated bruising on left trunk and recommended emergency room evaluation to rule out fracture. On 1/10/20, VA nurse re-evaluated R1 and noted R1 was alert, trunk and skin were inspected and no pain was assessed.

Continued on page 3.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2020

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20200109155457

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: SAKURA GARDENS VILLA LLC	FACILITY NUMBER: 435202531
	VISIT DATE: 06/03/2020

NARRATIVE

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A copy of the hospital after visit summary record was obtained dated 1/2/20 - 1/4/20. It was noted that R1 was diagnosed with Hematoma. There was no fracture indicated on the report.

Copies of letters written by staff and residents' family members were also obtained. Staff noted on their letters they are committed to provide good care to the residents. The family members noted on their letters that they have good experience with the facility and the staff.

Copies of staff training documentation were also obtained. Per review of the documents, staff are trained with assisting residents in transferring, helping up, walking, changing and re-positioning.

During subsequent visits, LPA observed that staff were assisting the residents properly and there were no injuries noted on the residents. LPA conducted a welfare check on R1 and was observed to be in good appearance and no injuries noted as well.

Per review of physician's report and needs and services plan, R1 was non-ambulatory and needs assistance with activities of daily living.

The Department has investigated the above allegation and based on the interviews, observation and review of records, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the above allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed on 6/3/2020 to the administrator for signature.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2020

LIC9099 (FAS) - (06/04)

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