435202665-4-17-2025-26-AS-KHOS-DFYKW5-20250422081523

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 04/17/2025
Date Signed: 04/17/2025 12:33:27 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
06/23/2022 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220623122726

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: 80	DATE:	04/17/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Business Office Director, Cassandra Pace		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Toxins are left accessible for the residents.

INVESTIGATION FINDINGS:

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On April 17, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Business Office Director, Cassandra Pace and explained the purpose of the visit.

Regarding the allegation toxins are left accessible for the residents, according to the reporting party, there was sunscreen, razor blades, perfumes and shampoo left under the sink and inside the shower of a resident’s room.

During the investigation, LPA observed 8 out of 10 resident apartments contained toxins and sharps that were accessible to residents. The toxins and sharps included items such as: hygiene products (shampoo, conditioner, soap, toothpaste), lotions, hair spray, perfumes, and electric razors. According to the Generations Director, these residents are not allowed to have access to hygiene items per their physician's report. The facility has been having issues with locking their cabinets due to the damaged locks.

Based on observations conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Business Office Director and a copy is provided with appeal rights.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cowan April	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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

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
06/23/2022 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220623122726

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:	04/17/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Business Office Director, Cassandra Pace		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff are not following physician orders
Facility does not have enough staff to meet the residents needs
Staff are leaving residents soiled

INVESTIGATION FINDINGS:

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On April 17, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Business Office Director, Cassandra Pace and explained the purpose of the visit.

Regarding the allegation, staff are not following physician orders, according to the reporting party, Resident 1 (R1) has a physician’s order for 24-hour oxygen using a concentrator, however on multiple occasions, it was observed that R1 was without the oxygen concentrator.

During the investigation, LPA reviewed R1's file, observed R1 and interviewed staff. Based on R1's physician's report R1 requires 24-hour oxygen using a concentrator. LPA observed R1 in the theater room joining an activity with the oxygen concentrator connected to the wall at the front of the theater room. According to staff interviewed, R1 requires to be on oxygen 24/7 and staff ensure that he/she has her oxygen all the time and ensure that she is near a power outlet when she leaves his/her room to go outside or do activities. It was also indicated that R1 does take off her oxygen, but staff will remind her to put it back on. (continue to 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cowan April	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20220623122726

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: 04/17/2025

NARRATIVE

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Regarding the allegation, facility does not have enough staff to meet the residents needs, according to the reporting party, it was observed that it was 11am and Resident 1 (R1) was still in bed, the blinds were closed, room was dark, and he/she still had not been fed breakfast.

During the investigation, LPA interviewed staff. Staff interviewed indicated that there is enough staff in memory care and they are also using agencies. In addition, staff interviewed indicated that staff work really closely together and are experienced. During the visit today, LPA observed 2 caregivers and 1 med-tech in the assisted living unit and 5 caregivers and 1 med-tech in the memory care unit.

Regarding the allegation, staff are leaving residents soiled, according to the reporting party, the facility staff are supposed to change and toilet the residents every couple hour, however while helping Resident 1 (R1), he/she was observed to be completely soaked.

During the investigation, LPA interviewed staff members. Based on staff interviews, residents are being checked on and changed every two hours or as needed if they soil themselves sooner.

Based on interviews conducted, observations and record review, the Department has determined that the above allegations are UNSUBSTANTIATED. 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.

Report is reviewed with the Business Office Manager and a copy is provided.

SUPERVISOR'S NAME: Cowan April	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20220623122726

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: 04/17/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/24/2025 Section Cited CCR 87309(a)	1 2 3 4 5 6 7	87309 Storage Space and Access: (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	All items were locked during the visit on 12/1/24. Deficiency is cleared and corrected.
	8 9 10 11 12 13 14	Based on observations 8 out of 10 resident apartments contained toxins and sharps that were accessible to residents which poses and immediate health and safety risk to residents 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: Cowan April	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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