435202580-5-18-2021-26-AS-MDON-C35RU4-20210518131916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202580
Report Date: 05/18/2021
Date Signed: 05/18/2021 01:19:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	WILLOW OAKS SENIOR CARE HOME		FACILITY NUMBER:	435202580
ADMINISTRATOR:	ABLAO, VICKY		FACILITY TYPE:	740
ADDRESS:	1573 WILLOW OAKS DRIVE		TELEPHONE:	(408) 267-5729
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	6	CENSUS: 5	DATE:	05/18/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Vicky Ablao		TIME COMPLETED:	01:30 PM

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On 5/18/2021 Licensing Program Analyst Marybeth Donovan and Gladys Kuizon Licensing Program Manager met with Vicky Ablao Licensee for a Case Management visit to follow up on a substantiated complaint regarding physical abuse of a resident.

On February 13, 2019, the Department concluded the complaint investigation, which alleged that the facility staff physically abused a resident (R1) at the facility intentionally, resulting in extensive injuries to R1.

The allegation was substantiated, and the licensee was cited for violating the Code of Regulations (CCR) Title 22, § 87468.1 (a)(3) Personal Rights for failure to ensure the resident to be free from punishment, humiliation, intimidation, abuse or other actions of punitive nature which resulted in physical abused of R1 by a facility staff.

On May 12, 2018, R1 was brought to the hospital emergency room via ambulance when the licensee and S1 noticed bluish discoloration on R1’s eyes and behind the ear but did not notice any swelling. S1 was not aware of what happened and thought the bruising spread from R1 picking R1’s eye on May 11, 2018 and had a small bruise on the left eye lid. A cold compress was applied on R1’s left eye. The hospital discovered that R1 had bruising to R1’s face, eyes, and left lateral chest wall. Medical authorities determined that R1 had Hematomas in two parts of R1 brain due to long-term fluid collection. Per medical-dictionary.com, Hematomas is a collection of extravasated blood clotted in an organ, space, or tissue.

The Department's investigation revealed that on May 11, 2018, facility staff intentionally physically abused R1 at the facility, resulting in extensive injuries to R1. During interviews, it was uncovered that S1 was the only caregiver alone with the R1 the entire day and overnight for approximately a 12-hour period prior to R1’s injuries.

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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: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: WILLOW OAKS SENIOR CARE HOME	FACILITY NUMBER: 435202580
	VISIT DATE: 05/18/2021

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Department's investigation also revealed that R1 is bedridden, non-ambulatory with no history of falls witnessed or documented. R1's extensive injuries are consistent with being pushed into the bed rail, indicating that R1's injuries were intentional. The Department's investigation revealed that S1 was known to become agitated with clients, argue over bathing clients, and force-fed the clients. Medical professional's records review indicates that R-1's injury could not have resulted from a fall. R1 's medical records also indicate that R1 was unable to roll on R1’s own and couldn't have received the injuries accidentally. Department's interviews revealed that S1 had shown behaviors that put clients at immediate risk for great bodily injury.

Based on the Department's investigations, observation, interviews, medical and police records review, and documents received revealed that staff physically abused R1 at the facility. Intentionally resulting in extensive injuries to R1. The licensee did not ensure that staff does not violate residents Personal Rights, which poses a potential health and safety risk to the residents in care.

At the time of the complaint visit on February 12, 2019, the issuance of a civil penalty was still being determined based on Health and Safety Code § 1569.49.

The Department has concluded the analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, May 18, 2021, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000.

A copy of the LIC 421D was given to Vicky Ablao Licensee and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Vicky Ablao Licensee signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

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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: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

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