435202665-7-14-2023-26-AS-RMAO-CU4N8H-20230726101422

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 07/14/2023
Date Signed: 07/14/2023 10:17:05 AM

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
08/30/2022 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20220830100730

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: 60	DATE:	07/14/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Becca Black		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff did not seek timely medical care for resident.

INVESTIGATION FINDINGS:

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

On 08/30/2022, the Department received a complaint regarding the above allegations. On 08/31/2022, the initial complaint investigation was conducted.

Throughout the investigation, the following documents were obtained to include resident (R1)’s physician’s report, service plan, medical records, hospice records, death report, death certificate, progress notes, and staff schedule from June 2022 – August 2022.

Based on record review, on 07/10/2022, resident (R1) tested positive for COVID-19.

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: 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 5

Control Number 26-AS-20220830100730

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

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On 07/16/2022, staff observed R1 was weak when attempting to get R1 out of bed for meals. It was noted that R1 was still testing positive, and fluids were being provided. On 07/17/2022, R1 was given PRN medication for symptoms. That night, R1 refused dinner and only drank fluids. There was no indication that a physician was being notified of R1’s condition.

On 07/18/2022 at 04:41am, R1 was observed very weak. Staff tried to hydrate R1 but R1 refused to drink fluids. A note on 07/18/2022 at 01:47pm states an outside agency Nurse Practitioner asked to have R1 sent out as R1 was not eating that morning, not responding to anything being told, and was only responding to pain. R1’s POA was at the facility. The nurse practioner assessed R1 and was sent to the hospital for medical treatment.

The review of R1’s medical records on 07/18/2022 states R1 was admitted and was diagnosed with altered mental status, dehydration, and other medical conditions. The medical record notes that R1 was in quarantine for x10 days and has been progressive more confused. On 07/27/2023, R1 returned to the facility under hospice care.

On 07/12/2023, 5 staff members were interviewed. Based on interview, staff (S3 – S5) stated to observe R1 was weak and tired during the time R1 had COVID-19 at the facility. Staff (S5) stated R1 was sent to the hospital due to a decline in R1’s health. Staff (S1) was unable to provide an explanation to why it took a couple days before R1 was sent out to the hospital despite showing signs of weakness.

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

A case management – deficiencies visit was conducted due to violations found during the complaint investigation. See LIC809 from 07/14/2023.

This report was reviewed with Interim Executive Director, Becca Black and a copy of the report and appeal rights were 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: 3 of 5

Control Number 26-AS-20220830100730

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: 07/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/15/2023 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will provide an in-service training for all staff. Facility has an all-staff meeting where the related topics will be covered. Facility will train new staff regarding the related topic going forward. Licensee will submit the in-service training document to LPA via email by POC due date.
	8 9 10 11 12 13 14	Based on record review, observation, and interview the Licensee did not ensure R1 was provided timely medical treatment after progressively being observed weak which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
08/30/2022 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20220830100730

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: 60	DATE:	07/14/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Becca Black		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Questionable death.
Facility is understaffed.

INVESTIGATION FINDINGS:

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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: 4 of 5

Control Number 26-AS-20220830100730

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

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On 07/10/2022, resident (R1) tested positive for COVID-19. On 07/18/2022, R1 was transported to the hospital due the observation of weakness. R1 was admitted to the hospital and discharged back to the facility on 07/27/2022 under hospice care due a decline in health.

On 08/02/2022, R1 passed away under hospice care.

Based on review of R1’s hospice records, R1 was admitted under hospice care with a terminal diagnosis of a neurodegenerative disease. The cause of death based on R1’s death certificate states complications of clinically diagnosed neurodegenerative disease.

The review of the staff schedule from July 2022 – August 2022 shows the facility was utilizing agency staff, most especially during the PM weekends of July 2022. The staff schedule shows the facility was providing at least 3-4 caregivers and 1 MedTech for AM/PM shifts and at least 2 caregivers and 1 MedTech for NOC shifts.

Based on interview, there was no indication that the facility was short-staffed as they were utilizing outside agency staffing, when needed.

The Department was investigated the above allegations. Based on record review, interview, and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegations may have happened and/or is valid there is not a preponderance of evidence to provide the allege 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: 5 of 5