435202621-7-30-2021-26-AS-KHOS-C68QWS-20210825123225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202621
Report Date: 07/28/2021
Date Signed: 07/30/2021 03:59:43 PM

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
05/06/2021 and conducted by Evaluator Anna Bui

COMPLAINT CONTROL NUMBER: 26-AS-20210506105038

FACILITY NAME:	SUNRISE VILLA SAN JOSE		FACILITY NUMBER:	435202621
ADMINISTRATOR:	ZEPEDA, JESSICA		FACILITY TYPE:	740
ADDRESS:	4855 SAN FELIPE RD		TELEPHONE:	(408) 223-1312
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	140	CENSUS: 85	DATE:	07/28/2021
		UNANNOUNCED	TIME BEGAN:	01:13 PM
MET WITH:	Jessica Zepeda		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Facility staff failed to seek timely medical attention for resident.
Facility staff did not provide assistance in a timely manner when resident asked for help.

INVESTIGATION FINDINGS:

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On 07/28/2021 at 1:13 pm, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced complaint investigation visit to deliver the findings to the above allegations. LPA met with Jessica Zepeda, Executive Director (ED).

-Continued, see LIC 9099-C (page 2 of 3).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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-20210506105038

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: SUNRISE VILLA SAN JOSE	FACILITY NUMBER: 435202621
	VISIT DATE: 07/28/2021

NARRATIVE

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Facility staff failed to seek timely medical attention for resident
Between 05/07/2021 – 07/20/2021, the Executive Director (ED) and 6 staff were interviewed. 7 out of 7 stated medical attention is never delayed when a resident needs it. 6 out of 7 stated when a resident has a fever, the resident’s temperature is retaken to confirm the temperature, and alternatives, such as medication or water, are offered to help lower the temperature. 6 out of 7 stated the resident is observed to see if the fever has improved; however, if it does not improve, staff reassesses the resident to determine if medical attention is needed or if 911 needs to be called.

Between 07/01/2021 – 07/16/2021, 6 residents were interviewed. 4 out of 6 residents stated when they fell or needed to go to the hospital, staff always checked on them right away or called 911 immediately. 1 out of 6 residents stated they never needed to go to the hospital or had a fall. 1 out of 6 residents did not comment on needing medical attention while at the facility.

6 resident’s documentation survey notes from May 2021 to June 2021 were reviewed and noted none of the residents having a fever. A review of the alleged victim’s (R1) records showed R1 did not have a fever on all of the days R1 was at the facility, and R1 ate R1’s meals and had no complaints while at the facility.

Facility staff did not provide assistance in a timely manner when resident asked for help
On 07/01/2021 and 07/20/2021, ED was interviewed. ED stated they have not told residents or family that staff will respond within a specific time frame; however, staff responds as soon as they can. ED stated there are times when staff respond to a call pendant, but they do not clear it right away. ED stated on 05/05/2021, it was Cindo de Mayo and there were several disruptive activities happening outside on the street that caused the road to the facility to be blocked. ED stated the disruptive activities and road blockage prevented some staff from leaving and entering the facility, which may have caused a delay in response time but assistance was provided to residents who asked.

On 07/06/2021, 6 staff were interviewed. 6 out of 6 staff stated their goal is to respond to a pendant call within 7 minutes. 5 out of 6 staff stated there has been times where it has taken longer than that, but they have not taken more than 30 minutes to respond to a call. 1 out of 6 staff stated they have always responded to a call pendant within 7 minutes. 6 out of 6 staff stated there is no required response time when a resident presses their pendant; however, all calls were responded to and necessary assistance were provided.
-Continued, see LIC 9099-C (page 3 of 3).

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20210506105038

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: SUNRISE VILLA SAN JOSE	FACILITY NUMBER: 435202621
	VISIT DATE: 07/28/2021

NARRATIVE

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Between 07/01/2021 – 07/16/2021, 6 residents were interviewed. 3 out of 6 residents stated when they pressed their call pendant, staff has always shown up within 15 minutes or less. 2 out of 6 residents stated they have not pressed their pendant, so they do not know how long it takes for a staff to respond; however, they stated staff always shows up when residents need assistance. 1 (R8) out of 6 residents stated they do not remember how long it takes for staff to show up when they press the pendant, but there has been a time where staff did not show up at all.

Facility’s records were also reviewed. 11 resident’s pendant call logs were reviewed randomly between April – July 2021. 2 out of 11 residents pendant call log showed wait time of more than 25 minutes from the time the pendant was pressed. R9’s pendant call log had 2 occasions of wait time of more than 25 minutes. R8’s pendant call log had 7 occasions of more than 25 minutes of wait time. It was unclear if this wait time was due to staff forgetting to reset or if it actually showed staff took that much time to respond. 9 out of 11 resident’s pendant call log showed wait time of 25 minutes or less, with various times ranging between 0 minutes to 25 minutes, and all calls were showed as responded to.

A review of the staff schedule for April - May 2021 showed no staff shortage. A review of the staff schedule for the day in question showed no staff shortage as well.

Facility’s Plan of Operation was also reviewed. The facility’s Plan of Operation does not state pendant calls have to be responded within a specific time frame.

Title 22 does not have a regulation that states pendants have to be responded to within a specific time frame.

The Department has investigated the above allegations. Based on interviews conducted and records reviewed, the Department found the above allegations to be 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 allegation did or did not occur.

An Advisory Note was issued, please see LIC 9102.

Exit interview was conducted with Jessica Zepeda, Executive Director. This report and LIC 9182 were reviewed with Jessica Zepeda, Executive Director, and copies were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

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