435202665-9-5-2024-26-AS-KHOS-D92SG2-20240912135112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 09/05/2024
Date Signed: 09/05/2024 11:15:41 AM

Unfounded

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
08/26/2024 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20240826104640

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: 81	DATE:	09/05/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Eugenia Smith		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff yelled at a resident
Staff mishandled a resident in a wheelchair

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin arrived unannounced to open the initial complaint investigation. LPAs met with Executive Director, Eugenia Smith.

On 08/26/2024, the Department received a complaint regarding the above allegations. On 09/05/2024, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1)'s physican report, service plan, progress note, identification and emergency contact information, 2 staff statements, 1 staff member's contact information, and email correspondence.
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Unfounded

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: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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-20240826104640

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: 09/05/2024

NARRATIVE

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On 09/05/2024, 2 staff members were interviewed. Based on staff interviews, it was stated that on 08/25/2024 an incident happened between resident (R1) and R1's family members. The front desk staff observed R1 and R1's family member having an argument in the facility's parking lot. The front desk staff called the memory care director for assistance, and by the time the memory care director arrived the resident was already inside the facility.

Based on interview and record review, the facility's staff were not in the parking lot and involved in the argument between R1 and R1's family members. Intervention with staff happened when R1 was already in the community.

The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unfounded meaning the allegations are false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited per California Code of Regulations, Tile 22.

This report was reviewed with Executive Director, Eugenia Smith and a copy of the report was provided.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC9099 (FAS) - (06/04)

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