435202665-4-4-2025-26-AS-KHOS-DFHSX5-20250407141522

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 04/04/2025
Date Signed: 04/04/2025 04:13:45 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
11/22/2022 and conducted by Evaluator Christine Kabariti

COMPLAINT CONTROL NUMBER: 26-AS-20221122103149

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:	DATE:	04/04/2025
		UNANNOUNCED	TIME BEGAN:	04:05 PM
MET WITH:	Eugenia Smith		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Facility staff did not ensure that resident's medical device (consentrator) was working properly.
Facility staff does not ensure that resident's room is free of odors.
Facility staff does not properly dispose of resident's soiled diapers.
Facility staff does not change resident out of their night clothes.
Facility did not take measures to ensure residents personal belongings doesn't go missing.
Facility staff do not wash resident's hands after meals.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director, Eugenia Smith.

On 11/22/2022, the Department received the complaint. On 12/02/2022, the initial complaint investigation was conducted.

The following documents were obtained to include facility's admission agreement, R1's physician's report, needs and services plan, medical notes, physician's order, progress notes, and safeguard of personal properties and valuables form.

It was alleged that staff did not ensure that resident (R1)’s medical device (oxygen concentrator) was working properly. It was alleged that on 10/25/2022, R1’s concentrator was not putting out air. Page 1 of 4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Kabariti	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

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 4

Control Number 26-AS-20221122103149

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: 04/04/2025

NARRATIVE

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Based on staff interview, it was stated that it was staff’s responsibility to keep an eye on R1’s oxygen concentrator to make sure it is working properly. Staff stated that R1’s family has complained that the light of the oxygen concentrator was turning yellow and now the staff are trained to contact the hospice agency if the oxygen concentrator light turns yellow. Staff denied the observation of the oxygen concentrator not working properly.

On 12/1/2022, LPA observed the light on R1’s oxygen concentrator was green.

Based on record review, the facility was monitoring R1’s oxygen concentrator, however, there were no notes on 10/25/2022 regarding R1’s oxygen concentrator not working properly.

It was alleged that facility staff did not ensure that resident’s room is free of odors as R1’s room smells like urine usually around 10:00am – 11:00am. It was stated that staff are masking the smell with Febreeze and since 11/24/2022, it hasn’t happened again for the past 3 weeks.

Based on staff interview, it was stated that staff try their best to air the resident’s room out if a resident soils their diapers, clothing and/or linens. Another staff stated that when a resident for example has a BM, they leave the smell because they are not allowed to have sprays. It was stated that if the resident is not in the room, they can open the window to air out, however, if the resident is in the room they don’t open the window because it can be too cold.

On 12/1/2022 around 10:45AM, LPA entered into 10 random apartments in memory care. LPA observed 1 out of 10 apartments had an odor of urine. Based on staff interview, staff was still working on getting the resident’s soiled laundry that was placed inside the resident’s hamper. LPA observed 9 out of 10 apartments did not have an odor of urine in the room.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Kabariti	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20221122103149

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: 04/04/2025

NARRATIVE

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It was alleged that staff did not properly dispose of resident’s soiled diapers.

Based on photographs obtained from the reporting party, it shows 2 pictures of black garbage bags that is tied and placed on the floor next to the resident’s hamper and placed on top of the resident’s bed. Based on the reporting party, the black garbage bag contained soiled clothing items.

Another picture shows a diaper that was placed on top of a table in which the reporting party stated was soiled. Based on observation of the picture, it is unclear whether the diaper was soiled as it only shows the outer part of the diaper.

On 12/1/2022, LPA entered into 10 random apartments in memory care. LPA observed 1 out of 10 apartments had soiled clothing inside of the resident’s hamper. Based on staff interview, staff was still working on getting the resident’s soiled laundry that was placed inside the resident’s hamper. LPA observed 1 out of 10 apartments did not have bed sheets. Based on staff interview, it was stated that the resident’s sheets were being washed because the bedding was soiled. LPA observed the remainder of the apartments did not contain any soiled items that were not disposed of properly to include diapers, linens, and clothing.

Based on staff interview, soiled diapers should be stored in a plastic bag and thrown out right away in the trash bins.

It was alleged that the facility staff does not change the resident out of their night clothes, as it was observed that R1 was sitting in the lobby in his/her nightgown before noon time.
Based on staff interview, it was stated that the residents clothes are changed when they help get them up in the morning before breakfast. It was stated when the PM shift starts (around 2:00pm), R1 was always observed in his/her day clothes. Staff denied observing R1 in his/her nightgown as R1’s family was so strict about ensuring R1 was changed out of his/her pajamas. Page 3 of 4.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Kabariti	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20221122103149

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: 04/04/2025

NARRATIVE

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On 12/1/2022 around 11:00am, all residents seated in activity room was observed dressed in day wear and not observed in pajamas and/or night gowns.

It was alleged that the facility did not take measures to ensure R1’s mattress pad did not go missing. It was stated that R1 and R1’s responsible party did not safeguard the items that went missing. It was stated that R1’s responsible party was reimbursed by the facility for the mattress bad.

Based on record review of R1’s safeguard of personal properties and valuables form, a “queen bed” was listed, however, it was unclear of what items of the queen bed was entrusted to the facility.

It was alleged that facility staff do not wash the resident’s hands after meals. The reporting party stated the observation of one incident where a staff member was getting towels and a washcloth stating it was to wash the resident’s hands, but the reporting party was unsure whether staff wash the resident’s hands every day.

Based on staff interview, it was stated that the staff are supposed to assist residents with hand washing before and after meals. Staff stated that hand washing also occurs after the resident uses the bathroom.

Based on record review, on 12/2/2022, the facility provided an in-service training with the staff regarding hand washing.

The Department has investigated the above allegations. Based on interview, record review 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 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 Executive Director, Eugenia Smith and Generations Program Director Erin Wiley and a copy of the report was provided.
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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Kabariti	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4