435202665-4-29-2025-26-AS-KHOS-DJ5ME5-20250630093210

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 04/29/2025
Date Signed: 04/29/2025 12:58:21 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
09/16/2024 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20240916090052

FACILITY NAME:	LOMA CLARA SENIOR LIVING		FACILITY NUMBER:	435202665
ADMINISTRATOR:	EUGENIA SMITH		FACILITY TYPE:	740
ADDRESS:	16515 BUTTERFIELD BLVD		TELEPHONE:	(669) 258-3500
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	89	CENSUS: 77	DATE:	04/29/2025
		UNANNOUNCED	TIME BEGAN:	09:56 AM
MET WITH:	Eugenia Smith		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Staff did not provide adequate supervision resulting in resident pushing another resident in care
Staff did not ensure resident was adequately fed resulting in weight loss
Staff did not inform resident's responsible party about resident's change of condition

INVESTIGATION FINDINGS:

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On 4/29/2025 LPA Grace Donato made an unannounced complaint investigation visit and deliver findings. LPA met with Executive Director (ED) Eugenia Smith. LPA explained the purpose of the visit.

Regarding the allegation of Staff did not provide adequate supervision resulting in resident pushing another resident in care, reporting party (RP) stated that the resident (R1) was at the facility for just about a year and was forced out due to an incident that occurred on 8/9/2024. R1 pushed another resident (R2), and they fell.

RP provided more information about the incident. RP shared that there was a first incident that happened between R1 & R2. RP was told by the staff that they couldn’t prove this happened where R1 went into R2s room and grabbed R2s arm. This is what RP was told. The MedTech’s said R1 was out the door already.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025

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-20240916090052

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: 04/29/2025

NARRATIVE

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They couldn’t prove it. There wasn’t any action plan the facility covered with RP. They said they didn’t really think it happened and supposedly they were keeping eye on them, don’t know if R1 was following R2 around. After the incident on 08/09, they met with them that Saturday morning and Maria (former memory care director) said it was really odd that it happened.

LPA Kabariti (Christine Dolores) interviewed staff members. According to ED, there was an incident that occurred between R1 and R2. Both residents are in memory care. There was a caregiver (S3), who saw them walking in the memory care's courtyard. There are windows to the courtyard and the caregiver clearly saw both residents. Both residents are ambulatory and independent. When R1 and R2 met at a crossing path, they don't know exactly what happened between them and what was said, but according to S3, R1 pushed R2 and R2 fell into the bush and ended up sideways from the walking path. LPA Donato was able to interview S3. S3 shared that he/she saw R1 push R2 so he/she ran to keep them away from each other.

Based on records review, in one of the entries in the progress notes, the former memory care director had a meeting with family members on 8/10/2024 to go over the service plan regarding the incident that happened.

Regarding the allegation of Staff did not ensure resident was adequately fed resulting in weight loss, RP stated that in the process of moving R1, RP learned he's lost 8 lbs. The reason R1 is in the facility is because R1 wasn't eating well at home and was only drinking calories so if anything, R1 should have gained weight with regular meals.

According to interviews, ED said that there were no concerns regarding R1s weight. R1 did a lot of walking and had a personal trainer that come here every week. Personal trainer was to keep him active. R1 was able to articulate and verbalize what he/she wanted. ED didn't notice he was losing weight. ED added that R1 verbalizes what he/she wants. If R1 needs more food, he/she asks for it.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20240916090052

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: 04/29/2025

NARRATIVE

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Based on records review, R1 had a logged weight record done by the facility every month. The records show that while the weight of the resident differs every month it is between 2.8lbs-6lbs. For July 1, 2024, the weight on record is 177.6 and when R1 got weighed again on August, 12, 2024, the records show 182lbs.

For the allegation that Staff did not inform resident's responsible party about resident's change of condition, RP shared that they have learned that R1 has a horrible nail fungus on the toes. Facility should have helped R1 shower so someone should have alerted us (RP) to the toe fungus problem.

During the interview, ED shared that they were not aware of any infections, fungus on R1s body and toe fungus. Don't remember anything of that effect. ED was not aware of any change of condition. If there was any change of condition it should be in the progress notes. ED also shared that R1 always has socks on. S2 mentioned that R1 was independent and performed his/her own Activities of Daily Living (ADL). S4 shared that he/she only observed R1s toenails to be long. If the fungus is under, then they won’t be able to see it. There is a podiatrist that comes in the facility to cut the residents nails. S4 also shared that R1 is good at dressing himself/herself.

According to the records reviewed, R1 is an ambulatory resident who can do his/her own bathing, dressing feeding and toileting needs. R1 is also capable of communicating his/her needs and can follow instructions. In R1s care plan, R1 needs verbal cue or reminders to shower, dress and groom. Care staff is to assist with setting out clean clothes and redirect verbally if needs change in clothing and show if needed. There is also verbal cueing to assist what comes next in grooming.

Based on interviews and records review, the department has determined that although the allegations 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.

Report is reviewed and copy is provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025

LIC9099 (FAS) - (06/04)

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