435202665-7-14-2023-26-AS-KHOS-CU3LSF-20230725090039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 07/14/2023
Date Signed: 07/14/2023 10:21:45 AM

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
01/23/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230123104002

FACILITY NAME:	LOMA CLARA SENIOR LIVING		FACILITY NUMBER:	435202665
ADMINISTRATOR:	JAIRUS CABUENA		FACILITY TYPE:	740
ADDRESS:	16515 BUTTERFIELD BLVD		TELEPHONE:	(669) 258-3500
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	89	CENSUS: 60	DATE:	07/14/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Becca Black		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee did not provide proper notice to the resident's representative within 2 business days of the rate increase after initially providing services

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding for the above allegation. LPA met with Interim Executive Director, Becca Black.

On 01/23/2023, the Department received the complaint. On 02/01/2023, the initial complaint investigation was conducted. It was alleged R1’s rate increased from being provided a one-to-one companion after an unwitnessed fall, despite the disapproval from R1’s representative.

From 02/01/2023 – 07/12/2023, documents were obtained to include resident (R1)’s admission agreement, physician’s report, service plan, care assessment, progress notes, invoice, and facility’s schedule of care fees. SEE LIC9099-C.

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: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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 2

Control Number 26-AS-20230123104002

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: 07/14/2023

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

The review of records shows on 01/18/2023, R1 sustained an unwitnessed fall and minor injury to the head. 911 was called but family refused to send R1 to the hospital as they felt it was not necessary. On 01/19/2023, a Nurse Practitioner evaluated R1 and encouraged R1 to be sent to the hospital for evaluation, however, R1’s family refused as they did not think it was necessary. Facility staff continued to monitor the resident. On 01/20/2023, it was noted that the Executive Director (ED) informed R1’s representatives of the facility’s responsibility to ensure R1’s safety after the fall by requiring a one-to-one companion during the night. The night of 01/20/2023, one-to-one companion was endorsed.

The review of R1’s January 2023 invoice did not indicate a service for a one-to-one companion was charged.

Based on interview on 02/01/2023, the ED stated R1 was not billed for the one-to-one companion due to R1’s departure from the facility on 01/28/2023.

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

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Interim Executive Director, Becca Black 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: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2