435202665-3-12-2025-26-AS-KHOS-DFHT64-20250407142632

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 03/12/2025
Date Signed: 03/12/2025 03:53:03 PM

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
03/10/2025 and conducted by Evaluator Christine Kabariti

COMPLAINT CONTROL NUMBER: 26-AS-20250310163510

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: 74	DATE:	03/12/2025
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Cassandra Pace		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff physically abused resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to open the initial complaint investigation. LPA met with Business Office Director, Cassandra Pace.

On 03/10/2025, the Department received the complaint. On 03/12/2025, the initial complaint investigation was conducted. The following documents were obtained to include: resident roster in Generations (aka memory care), staff schedule in Generations, resident (R1's) physician's report, services plan, progress notes from January - March, face sheet, and other medical correspondence.

It was alleged that a facility staff had physically abused a resident (R1) by picking him/her up, carrying him/her, and putting him/her down causing R1 to have shoulder and hip pain. The alleged staff was described to be a tall male caregiver. Page 1 of 2.

Unfounded

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: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

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-20250310163510

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: 03/12/2025

NARRATIVE

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Based on interview with staff (S1), it was stated that during R1's medical appointment, R1 informed his/her doctor of an incident that occurred with R1 and a former resident back in August 2024 wherein a male resident had pushed R1 in the courtyard. Since then, R1 had complained of leg pain. S1 denied any incidents of a staff member physically abusing R1. It was stated that R1 is fully ambulatory and is able to provide his/her ADL (activities of daily living) care to include getting in and out of bed. It was stated that R1 only needs assistance with medication and stand-by showers provided by female caregivers. S1 stated that they have 2 male caregivers in Generation who do not provide any care to R1, due to R1's preference.

On 03/12/2025, a witness was interviewed. Based on interview, it was stated that the incident did not occur with a staff but rather with a former resident. The witness did not have any complaints or concerns regarding staff treatment towards R1.

On 03/12/2025, resident (R1) was interviewed. Based on interview, R1 denied any staff members hurting him/her. R1 states that he/she does most ADL care by him/herself and only needs stand-by assistance during showers and assistance with medication. R1 denied any male caregivers providing any care to R1 and states only female caregivers provides care to R1.

On 03/12/2025, a staff member was interviewed. Based on interview, the male caregivers do not provide any physical care to R1.

Based on record review, R1 is diagnosed with vascular cognitive impairment.

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

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Business Office Director, Cassandra Pace and Generations Program Director Erin Wiley and a copy of the report was provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Kabariti	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC9099 (FAS) - (06/04)

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