435202540-1-4-2023-26-AS-KHOS-CMXP5W-20230110100125

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202540
Report Date: 01/04/2023
Date Signed: 01/04/2023 04:08:32 PM

Unfounded

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
12/03/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20211203134032

FACILITY NAME:	AMY'S SENIOR CARE INC		FACILITY NUMBER:	435202540
ADMINISTRATOR:	MANN, AMARJEET		FACILITY TYPE:	740
ADDRESS:	701 N WHITE ROAD		TELEPHONE:	(408) 926-7308
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	6	CENSUS: 6	DATE:	01/04/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Amarjeet Mann		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident is in need of hearing aids.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted a complaint investigation visit to deliver investigation findings. LPA met with administrator (ADM) Amarjeet Mann.

On 12/03/2021, the Department received a complaint regarding the above allegations. An initial investigation visit was conducted on 12/10/2021. ADM, one staff (S1) and resident R1 were interviewed. LPA interviewed R1's conservators (C1-C2) by phone. R1's Physician’s Report’s (LIC602), Appraisal/Needs and Service Plan (LIC625) and Functional Capability Assessment (LIC9172) were obtained.

Continued, see LIC 9099-C, page 1 of 2.

Unfounded

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: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

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 4

Control Number 26-AS-20211203134032

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: AMY'S SENIOR CARE INC	FACILITY NUMBER: 435202540
	VISIT DATE: 01/04/2023

NARRATIVE

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Resident is in need of hearing aids:

On 12/10/2021, and 05/19/2022, LPA interviewed ADM. ADM stated facility provided ear phone to R1 when R1 watches TV or when listens to music. R1 was seen by two doctors who conducted hearing tests for R1 on 3/17/2022 and 3/31/2022. Both doctors did not recommend R1 to wear hearing aids.

Based on the documents reviewed and interviews conducted, R1 is not in need of hearing aids.

The Department has investigated the above allegations. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview was conducted with ADM. A copy of this report was provided to ADM.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4

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
12/03/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20211203134032

FACILITY NAME:	AMY'S SENIOR CARE INC		FACILITY NUMBER:	435202540
ADMINISTRATOR:	MANN, AMARJEET		FACILITY TYPE:	740
ADDRESS:	701 N WHITE ROAD		TELEPHONE:	(408) 926-7308
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	6	CENSUS: 6	DATE:	01/04/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Amarjeet Mann		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident is in need of dental x-ray.

INVESTIGATION FINDINGS:

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Unsubstantiated

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: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20211203134032

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: AMY'S SENIOR CARE INC	FACILITY NUMBER: 435202540
	VISIT DATE: 01/04/2023

NARRATIVE

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Resident is in need of dental x-ray:

On 12/10/2021, LPA interviewed staff S1. S1 stated facility caregivers assisted R1 to brush teeth daily. On 12/10/2021 and 05/19/2022, LPA interviewed ADM. ADM stated that facility requested a dentist to come facility to check and evaluate R1's teeth on 11/01/2021. Dentist did not recommend dental X-ray. ADM stated the facility had dentist regularly came to facility to check and evaluate residents' teeth. ADM stated the facility caregivers check/monitor R1's teeth every day, and help R1 to brush teeth twice every day.

On 9/22/2022, LAP interviewed ADM. ADM stated R1's teeth have no problem. ADM stated R1 has no problem for eating, and R1 eats 3 meals every day. ADM stated caregivers assist R1 to brush teeth daily. ADM stated dentist said R1 has no problem for R1's teeth.

On 1/3/2023, LPA received the doctor's report in writing. The doctor suggested Dental X-ray for R1 if R1 can tolerate the procedure. The doctor did not specify whether R1 can tolerate the procedure or not.

The department has investigated the above allegation. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No citations noted at today’s complaint investigation visit. Exit interview was conducted with ADM. A copy of this report was provided to ADM.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4