435202536-11-4-2021-26-AS-SYIP-C9FVXA-20211206154913

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202536
Report Date: 11/04/2021
Date Signed: 11/04/2021 12:42:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2020 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20200617154124

FACILITY NAME:	WEST VALLEY CARE HOME		FACILITY NUMBER:	435202536
ADMINISTRATOR:	ZHANG, BIAO		FACILITY TYPE:	740
ADDRESS:	15 DARRYL DRIVE		TELEPHONE:	(408) 418-8188
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	6	CENSUS:	DATE:	11/04/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Biao Zhang		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Facility staff left resident in soiled clothing for extended periods of time
Lack of supervision resulting in resident sustaining multiple falls
Facility is not communicating with resident's hospice
Facility is not dispensing resident's medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Marybeth Donovan and Christine Dolores arrived unannounced to deliver the complaint investiation findings.

Allegation: Facility staff left resident in soiled clothing for extended period of time
Between 06/25/2020-07/13/2020 a total of two staff members were interviewed. 2 out of 2 staff stated they were not aware of a time a resident was left in soiled clothing for an extended period of time. Staff stated residents are checked frequently to ensure they are not left in soiled clothing.

Between 06/25/2020-08/05/2020 a total of six residents were interviewed. 6 out of 6 residents stated that residents were not left in soiled clothing for an extended period of time. Residents stated staff check on the residents to ensure they are dry.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

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-20200617154124

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: WEST VALLEY CARE HOME	FACILITY NUMBER: 435202536
	VISIT DATE: 11/04/2021

NARRATIVE

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On 06/25/2020 LPA Jackie Jin toured the facility via FaceTime. Residents were observed clean and engaged in activities of their choice.

Allegation: Lack of supervision resulting in resident sustaining multiple falls
Between 06/25/2020-07/13/2020 a total of two staff members were interviewed. 2 out of 2 staff stated R1 falls at night between 3am-5am. R1 was using the bathroom and does not want staff to be in the bathroom with R1. Staff get up during the night to check on the residents. All staff stated the residents do not need constant supervision. S1 stated that to prevent residents from falling, the bathroom has grab bars and nonskid mats, and the residents has half bed rails and the beds are lowered.

Between 06/25/2020-08/05/2020 a total of six residents were interviewed. 5 out of 6 residents stated when a resident has fallen, staff will assist the resident back up and check for injuries. One resident does not recall falling at the facility.

Incident report reviewed and noted R1 had two falls, one fall on 06/09/2020 at 3:15am and another fall on 06/13/2020 at 1:05am while going to the bathroom. The facility administrator and staff observed the incident. R1 was accessed for injuries and no injuries were noted. R1’s hospice agency was notified. After this incident, the facility plan was to have more supervision for R1 during the day and requested a different walking aid.

Hospice plan of care indicated R1 is a high risk for falls. The facility staff will assist R1 to the bathroom during awake hours and bedtime. The facility will keep the path clear, label the bathroom, and leave the door open.

Allegation: Facility is not communicating with resident hospice
Hospice notes indicated that on 06/05/2020 and 06/11/2020 the hospice nurse and social worker attempted to contact the facility owner and it went straight to voicemail. Several call attempts were made, and the facility owner did not return call. Hospice notes also indicated that on 06/11/2020 the social worker called the facility owner through an unblocked number, and the social worker was able to speak to the facility owner.

On 06/25/2020 S1 was interviewed and stated the facility landline goes directly to S1’s cellphone when someone calls. S1’s cellphone is available 24/7 and S1 can be reached after 7pm. S1’s cellphone initially was set up to Block an unknown a caller ID. S1 stated to prevent communication issues S1 changed the cellphone set up to receive calls from the hospice agency.
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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20200617154124

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: WEST VALLEY CARE HOME	FACILITY NUMBER: 435202536
	VISIT DATE: 11/04/2021

NARRATIVE

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Between 07/13/2020-08/06/2020 LPA contacted facility administrator at 10:51am, 10:56am, and 7:04pm. Facility administrator responded to LPA’s calls and returned call when a voicemail was left.

Allegation: Facility is not dispensing the resident’s medication as prescribed
On 06/25/2020 S1 was interviewed and stated on 06/11/2020 there was a doctor’s order to increase prescription medication to 100mg, however, the doctor’s order was not sent to the doctor or to the pharmacy by the hospice nurse. S1 followed up with the hospice nurse on 06/16/2020, and new order for prescription medication was sent to the pharmacy. The facility received R1’s medication on the same day and started the medication.

3 out of 6 residents stated staff monitors their medications. Three residents stated they did not take medications at the facility.

On 08/28/2020 LPA Jackie Jin conducted a medication audit via FaceTime with Administrator. Based on observation of medication audit, LPA is not able to determine if facility followed doctor's order when giving medication. Administrator did not indicate or recall start dates of medications. LPA is unable to determine how many pills were left in for each medication based on the quantity of medication prescribed and how long the residents were taking their medications.

Doctor’s order for prescription medication was reviewed and it indicated that on 06/11/2020 prescription medication 100mg was ordered. Per Administrator, there was mis-communication between the hospice agency and the doctor’s order for prescription medication 100mg and a new doctor’s order was completed on 06/16/2020. Medication packing slip shows prescription medication 100mg was dispensed on 06/16/2020. Medication Administration Records (MAR) indicated that R1 began to take prescription medication 100mg on 06/16/2020 and was given daily at bedtime. MAR did not indicate any refusal of this medication.

This Department has investigated the above allegations, and based on interviews, records review, and observations the Department has determined that the allegations were Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. This report was reviewed with Biao Zhang a copy of this report provided.
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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC9099 (FAS) - (06/04)

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