435202665-2-1-2023-26-AS-KHOS-CU3LSG-20230725090040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 02/01/2023
Date Signed: 02/01/2023 04:52:32 PM

Substantiated

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:	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Jairus Cabuena		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility does not lock toxins
Facility's stairwells are not free of obstruction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open a complaint investigation. LPA met with Memory Care Director (MCD), Maria Martinez and Executive Director (ED), Jairus “Jett” Cabuena.

During today’s visit, LPA toured the Memory Care section with MCD to include 10 out 25 resident apartments, bathrooms, activity room, 2 out of 2 stairwells, and exterior. LPA interviewed 3 staff members.

Documents were obtained to include the generations roster, R1's residence and care assessment, physician reports, service plan, care assessment, progress notes, R2 - R3's physician's report, and facility's in-service training.

See LIC9099-C.

Substantiated

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)

Page: 1 of 3

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/02/2023 Section Cited CCR 87307(d)(6)	1 2 3 4 5 6 7	(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee immediately corrected the deficiency by removing the large items in the stairwell. Licensee will submit a statement of understanding to ensure all stairwells and passageways will be kept free and clear of obstruction to LPA via email by POC due date.
	8 9 10 11 12 13 14	Based on observation, 1 out of the 2 facility stairwells contained large items that were obstructing the passageway which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
Type A 02/02/2023 Section Cited CCR 87705(f)(1)	1 2 3 4 5 6 7	(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee immediately secured the toxins. Licensee will provide an in-service training to all staff regarding the importance of keeping toxins inaccessible. Licensee will submit the training documents and statement of understanding of section 87705 to LPA by POC due date.
	8 9 10 11 12 13 14	Based on observation and record review, LPA observed toxins were accessible inside a residents apartment whom should not have access to hygiene items which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

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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: 02/01/2023

NARRATIVE

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Based on observation, accessible toxins (shampoo, body wash, lotions, toothpaste, and perfumes) were observed in 2 out of 10 resident apartments in memory care. The toxins were immediately locked during the visit. Based on record review, 1 out of the 2 residents may not have direct access to personal hygiene items.

Based on observation, 1 out of the 2 facility stairwells contained large items that obstructed the passageway. Facility staff immediately removed the items during the visit and LPA observed the stairwell to be free and clear of obstruction.

The Department has investigated the above allegations and the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies were cited per California Code of Regulations, Title 22. See LIC9099-D.

A plan of correction was developed with the Executive Director and a copy of the report and appeal rights 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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