435202665-6-25-2020-26-AS-RMAO-BRELZW-20200711091238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 06/25/2020
Date Signed: 06/25/2020 12:09:08 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
11/05/2019 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20191105131840

FACILITY NAME:	LOMA CLARA SENIOR LIVING		FACILITY NUMBER:	435202665
ADMINISTRATOR:	BATTON, TIM		FACILITY TYPE:	740
ADDRESS:	16515 BUTTERFIELD BLVD		TELEPHONE:	(669) 258-3500
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	89	CENSUS: 48	DATE:	06/25/2020
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Jolie Higgins		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not meeting the needs of the residents
Staff are failing to assist with incontinence care
Staff is unqualified to assist with the administration of medications

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 11/05/2019 CCDS received the complaint allegations as follows: Staff are not meeting the needs of residents; Staff are failing to assist with incontinence care; and Staff is unqualified to assist with the administration of medications.

On 6/25/2020 Licensing Program Analyst (LPA) Marybeth Donovan conducted a Tele-Visit to deliver the complaint investigation findings. Due to the Corona Virus 2019 Disease, the Department has suspended on-site inspections at this time. LPA discussed this report with Jolie Higgins Executive Director.

On 11/15/2019 Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to open a 10 day complaint investigation. LPA met with Tim Batton Senior Executive Director (Sr. ED) and toured the facility. LPA interviewed three staff members (S1-S3) and six residents (R1-R6) and reviewed seven resident and four staff files.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

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-20191105131840

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: LOMA CLARA SENIOR LIVING	FACILITY NUMBER: 435202665
	VISIT DATE: 06/25/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 11/15/2019 LPA obtained records to include in part, resident and staff rosters, Admission Agreements, Medical Records, Generations Monthly Staff schedule, Group Assignments, Shower Log, Laundry Schedule and Bowel Movement Log.

On 4/29/2020 LPA interviewed S4 by telephone.

On 5/8/2020 LPA reviewed additional employee records.

On 5/28/2020 LPA interviewed three staff S5-S7 and one family member F1 by telephone.

On 5/29/2020 LPA interviewed one staff S8 by telephone

The reporting party stated that staff do not respond to residents call for toileting assistance and the residents’ soil themselves. On another occasion a resident slept in bed soiled with cat vomit because staff refused to change the bed sheets. Family member did not observe cat vomit on the bed and was unable to confirm the facts with R7. S7 cleaned the cat vomit and changed R7’s bedding. S7 believed that R7 was unaware of the vomit on the bed. S7 denies any staff refusal to clean R7’s bedding or address R7’s care needs.

Also, the reporting party stated that caregivers not trained in medication administration were giving medications to residents.

All staff interviewed S1-S8 deny both not meeting the needs of residents and failing to assist residents with incontinence needs. Housekeeping cleans each resident’s rooms on a weekly basis or as requested. Caregivers upon entering a room will remove trash or dishes as required to keep the room clean and sanitary. Caregivers will also do residents personal laundry weekly or as needed to include linens.

Seven of eight staff S1-S7 deny unqualified staff administered medication to residents. S8 job duties do not involve medication administration. These staff confirmed only Med Techs are allowed to administer medications. Caregivers do not administer or help with medications.

Review of training records indicate four of four staff completed the required initial 24 Hours of training prior to administering medication.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20191105131840

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: LOMA CLARA SENIOR LIVING	FACILITY NUMBER: 435202665
	VISIT DATE: 06/25/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Family member F1 interviewed stated that they did not have any concerns regarding the R7’s care needs to include toileting. R7 managed R7’s own medication and did not need medication management. F1 did not have any direct knowledge of any issues with staff administering medications to other residents.

Based on information from interviews conducted with residents, staff, family and records reviewed, although the allegations listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Jolie Higgins Executive Director and a copy of this report provided via email for signature purposes.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

LIC9099 (FAS) - (06/04)

Page: 3 of 3