435202651-2-19-2025-26-AS-RMAO-DEE72U-20250302201720

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202651
Report Date: 12/06/2024
Date Signed: 02/19/2025 04:01:39 PM

Unsubstantiated

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
10/28/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20241028165255

FACILITY NAME:	MERIDIAN MANOR IV		FACILITY NUMBER:	435202651
ADMINISTRATOR:	EMMANUEL G FERNANDO		FACILITY TYPE:	735
ADDRESS:	1502 CONSTANSO WAY		TELEPHONE:	(408) 882-3908
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY:	3	CENSUS: 3	DATE:	12/06/2024
		UNANNOUNCED	TIME BEGAN:	01:02 PM
MET WITH:	Emmanuel Fernando		TIME COMPLETED:	01:53 PM

ALLEGATION(S):

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The licensee did not ensure care and supervision was to provided to meet the needs of a resident that resulted in a right humerus fracture.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Administrator (ADM) Emmanuel Fernando.

On 10/28/2024, the Department received a complaint with the allegation that the facility staff did not ensure care and supervision were provided to resident R1 resulting in R1 obtained a fracture.

On 10/31/2024, the Department conducted an initial investigation visit.

LPA interviewed ADM, 4 staff. LPA tired to interviewed 3 residents, 3 residents are nonverbal.

LPA requested roster of clients, staff schedule, staff's statement, resident's physician report, IPP, and Appraisal Needs and Service Plan.
Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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-20241028165255

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: MERIDIAN MANOR IV	FACILITY NUMBER: 435202651
	VISIT DATE: 12/06/2024

NARRATIVE

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The licensee did not ensure care and supervision was to provided to meet the needs of a resident that resulted in a right humerus fracture:
On 10/31/2024, LPA interviewed Administrator (ADM). ADM stated on 10/26/2024, around 12:00PM - 12:30PM, he/she received a phone call from staff S1 saying he/she found resident R1's right arm was not moving and R1 only used left hand to eat lunch, that was different from R1's usual behavior.

ADM stated he/she came to the facility immediately to assess R1, he/she and staff S3 sent R1 to Urgent Care around 2:30PM. R1 had fracture on his/her upper right arm per X ray result. Per Urgent Care doctor instruction, R1 was sent to hospital emergency room around 6:30PM. R1 was discharged from hospital around 9:00AM on 10/27/2024.

ADM stated he/she conducted an internal investigation on 7 staff(S1, S2, S3, S5, S6, S7, S8), but does not know what happened to R1. ADM provided a copy of the 7 staff written statements.

ADM stated R1 does not have seizure and no one saw R1 fell. ADM stated the facility night staff (S6, S7) helped R1 went to restroom around 4:00AM on 10/26/2024. ADM stated S6 and S7 did not report any incident to the morning staff S1 and S2.

On 10/31/2024, LPA interviewed staff S1 on the phone. S1 stated on 10/26/2024, he/she started his/her duty at the facility at 8:00AM. S1 stated R1 was sleeping when he/she started his/her duty. S1 stated the night shift staff S6 and S7 did not report any incident of R1 to him/her. S1 stated R1 woke up around noon time on 10/26/2024. S1 stated he/she was assisting R1 for toileting and shower. S1 stated he/she found R1 was unable to move his/her right arm and called staff S2 to check R1. S1 stated he/she and S2 confirmed R1's right arm was painful and was unable to move and he/she reported to Administrator before 12:30PM.

LPA interviewed 3 residents. 3 Out of 3 residents are nonverbal.

LPA interviewed staff S3. S3 stated he/she and ADM sent R1 to urgent care and hospital. S3 stated he/she did not see R1 fell. S3 stated he/she did not see or hear any one hit R1. S3 stated he/she does not know what happened to R1.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20241028165255

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: MERIDIAN MANOR IV	FACILITY NUMBER: 435202651
	VISIT DATE: 12/06/2024

NARRATIVE

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LPA interviewed staff S4. S4 stated he/she was off on 10/26/2024 and 10/27/2024. S4 stated he/she did not see R1 fell. S4 stated he/she did not see or hear any one hit R1.

LPA interviewed staff S5. S5 stated he does not know what happened to R1. S5 stated on 10/28/2024 he/she heard R1 was sent to hospital. S5 stated he/she did not see R1 fell. S5 stated he/she did not see or hear any one hit R1.

Based on the interview with staff, there is no staff observed R1 fall, no staff saw or heard R1 was hit or physically abused, and no one know what happened to R1.

Based on the review of the 7 staff written statements, 7 out of 7 staff are unaware of what happened to resident R1. 7 out of 7 staff did not see R1 fell. 7 out of 7 staff did not see or hear any one hit R1.

Based on the review of R1's Individual Program Plan (IPP) dated 7/12/2023, R1 displays self injurious behavior.

Based on the review of R1's Emergency room visit summary dated on 10/26/2024, it does not specify the possible reason for R1's fracture.

On 01/09/2025, LPA interviewed R1's Service Coordinator (SC). SC stated he/she is aware of the R1's incident. SC stated he/she reviewed the statements of the 7 facility staff and reviewed R1's discharge medical documents. SC stated he/she does not have conclusion of finding for R1's incident.

Based on the interview, and records reviewed, there is no evidence to indicate that staff lack of supervision resulting in resident R1 obtaining fracture.

Based on investigation, interviews conducted and records reviewed , the Department found that the above allegation is 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 compliant investigation visit. Exit interview conducted with ADM. A copy of this report was provided to ADM. Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20241028165255

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: MERIDIAN MANOR IV	FACILITY NUMBER: 435202651
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/07/2024 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078 Responsibility for Providing Care and Supervision, (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated to send a plan of correction by the POC due date to ensure residents to receive the necessary care and supervision, and provide the staff traoinin on how to provide care and supervision. ADM stated to send the staff training log to CCL office.
	8 9 10 11 12 13 14	Based on interview and record reviewed, the facility lack of care and supervision resulting in resident R1 obtained fracture which poses/posed an immediate health, safety or personal rights risk to persons 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.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4