435202536-3-20-2023-26-AS-KHOS-CRFH3U-20230502055053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202536
Report Date: 03/20/2023
Date Signed: 03/20/2023 11:37:18 AM

Substantiated

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
12/09/2020 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20201209171404

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: 6	DATE:	03/20/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Biao Zhang		TIME COMPLETED:	11:41 AM

ALLEGATION(S):

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Lack of staff supervision resulted in resident elopement from the facility.

INVESTIGATION FINDINGS:

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Licesning Program Analyst Ryker Heberle (LPA) conducted an unannoucned complaint inspection to deliver the findings regarding the above allegation. LPA met with facility administrator Biao Zhang (Admin).

During complaint investigation on 12/18/2020, Admin confirmed that a resident (R1) had eloped from the facility on 11/25/2020 at 04:27am. Review of photographic evidence from facility exterior security cameras confirm time of resident elopement. Admin stated that he was unaware of live in staff member's activity during time of elopement. According to Admin, Staff discovered R1 had eloped at approximately 07:00am. Review of facility LIC 500 indicated that the facility had 1 staff member on shift during the time of the elopement.

Continued on 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

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-20201209171404

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: WEST VALLEY CARE HOME	FACILITY NUMBER: 435202536
	VISIT DATE: 03/20/2023

NARRATIVE

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During interview, Admin stated that the facility did not have any residents that were unable to leave the facility unassisted, however, during review of R1's physician's report, it was indicated that R1 was not permitted to leave the facility unassisted. Admin provided written correspondence with R1's family regarding R1's care at the facility. Text messages indicate that from dates ranging between September 2020 and December 2020, Admin had maintained consistent correspondence with R1's family, and had stated that R1's care needs, particularly as it pertained to wandering, have elevated beyond what the facility can provide, and indicated that both parties had been searching for alternative placement for that entire period, both parties had difficulty finding placement for the resident due to the COVID-19 pandemic.

Since the elopement, staff has installed a wireless door alarm to alert staff of potential resident elopements. LPA observed the wireless door alarm to be operation during this visit.

In review of photographic evidence submitted by a witness and facility incident report written regarding the elopement, it is confirmed that R1 sustained a bump on their head as well as bruising around the eye during the period in which R1 was not on the premises.

The Department has conducted an investigation of the above allegation. Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Deficiency is being cited and civil penalty is being assessed. See LIC 9099-D and LIC421.

This report was reviewed with Administrator Biao Zhang and a copy of the signed report was provided via email due to printer error.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20201209171404

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: WEST VALLEY CARE HOME	FACILITY NUMBER: 435202536
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/21/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall... include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee increased night shift monitoring of residents. Door alarms were implemented. LPA observed documentation of daily resident checks and alarm door checks. POC observed to be completed on site.
	8 9 10 11 12 13 14	Based on interviews and records review, Staff (S1) did not ensure resident (R1) who can’t leave facility unassisted was supervised while leaving the facility. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC9099 (FAS) - (06/04)

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