435202665-2-1-2023-26-AS-KHOS-CQCJDG-20230328065727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 02/01/2023
Date Signed: 02/01/2023 05:00:00 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
08/29/2022 and conducted by Evaluator Christine Dolores

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220829084324

FACILITY NAME:	LOMA CLARA SENIOR LIVING		FACILITY NUMBER:	435202665
ADMINISTRATOR:	DIANA SMITH		FACILITY TYPE:	740
ADDRESS:	16515 BUTTERFIELD BLVD		TELEPHONE:	(669) 258-3500
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	89	CENSUS: 65	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	04:55 PM
MET WITH:	Jairus “Jett” Cabuena		TIME COMPLETED:	05:05 PM

ALLEGATION(S):

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Staff did not follow resident's care plan
Resident received a fracture while in care due to staff negligence

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director (ED), Jairus “Jett” Cabuena.

On 08/29/2022, the Department received the complaint and conducted the initial complaint investigation.

From 08/29/2022 – 01/31/2023, the following documents were obtained to include R1’s residence and care agreement, progress notes, service agreement, care assessment, physician’s report, medical records, R2 – R4’s files, staff schedule and profiles, and resident list.

On 08/24/2022, R1 sustained a witnessed fall resulting in hospitalization due to laceration and a fracture. It’s alleged the facility did not follow R1’s care plan by not providing a two-person assist.

See LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20220829084324

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: LOMA CLARA SENIOR LIVING	FACILITY NUMBER: 435202665
	VISIT DATE: 02/01/2023

NARRATIVE

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Based on interview, staff (S1) witnessed R1’s fall. S1 was wheeling R1 out of the shower room, when R1 grabbed onto the door frame and pulled themselves forward falling headfirst. S1 states to have never left R1 alone and was in proximity. S1 states to try grabbing onto R1’s shoulder to lean it back but was unable to react quickly enough to prevent the fall. S1 was aware of their procedures for a two-person assist for transfers, however, S1 believed showers and transporting from one room to another was a one-person assist. S1 states another staff helped transfer the resident to the wheelchair to shower.

2 staff were interviewed. 2 out of 2 staff believe the incident was not due to lack of supervision. 2 out of 2 staff state R1 requires a two-person assist for transfers to and from the wheelchair.

Based on record review, R1’s signed service agreement only states a one-person assist for bathing. Other services such as dressing, grooming, and toileting only notes as “req assist” with no specific number of caregivers. R1 is a fall risk, and the facility notes actions to help reduce the risk of falls.

The Department has investigated the above allegations. Based on interview and record review, the Department has determined 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 the alleged violations did or did not occur.

No deficiencies are being cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director (ED), Jairus “Jett” Cabuena and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

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