435202665-12-30-2025-26-AS-RMAO-DQNVXH-20260125154934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 12/30/2025
Date Signed: 12/30/2025 01:09:27 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
11/18/2025 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20251118163955

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: 71	DATE:	12/30/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Cassandra Pace		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

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Staff did not take the necessary precautions to prevent the resident from overdosing on medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Senior Business Office Director (BD) Cassandra Pace.

On 11/18/2025, the Department received a complaint with the allegation that staff did not take the necessary precautions to prevent the resident from overdosing on medication.

On 11/20/2025, the Department conducted an initial investigation visit.

LPA interviewed Ed, 4 staff, and resident R1.

LPA toured resident R1's room.

Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025

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 3

Control Number 26-AS-20251118163955

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: 12/30/2025

NARRATIVE

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On 11/20/2025, LPA interviewed Executive Director (ED), ED stated resident R1 lives in the assisted living unit. ED stated R1 had doctor prescription medication 25 mg M1 to take one pill as needed at bedtime to help for sleeping. ED stated the facility did not know that R1 ordered the medication M1 by himself/herself and hid in his/her room. ED stated on 11/13/2025, R1's family member (FM) visited R1 and found R1 had symptoms of stroke and called 911. R1 was sent to hospital. ED stated on 11/14/2025, R1 told hospital nurse that he/she had trouble of sleeping and took several pills of medication M1 per day.

ED stated R1 ordered M1 online and the package of M1 was delivered to the facility. ED stated the facility did not open R1's package because of the right of privacy. ED stated R1 did not tell any facility staff that he/she ordered medication M1 online. ED stated the facility staff did not see medication M1 in R1's room because R1 hid it. ED stated R1 had packages from Amazon delivered to the facility on 09/30/2025, 10/102025, 10/142025, 10/15/2025, and 11/10/2025 but were unable to know which packages had medication M1. ED stated on 11/17/2025, FM came to R1's room to search R1's room and took all medication M1 from R1's room and R1's Amazon account was closed by FM. ED sated on 11/17/2025, R1's doctor stopped the prescription of medication M1.

On the same day, LPA interviewed R1 in R1's room. R1 stated he/she had medication M1 several pills per day before but not recently. R1 stated he/she does not remember the exact date that he/she stared to take M1. R1 stated the reason that he/she takes M1 is because he/she wants to have good sleep. R1 stated there is no more M1 in the room because FM removed all M1 from the room. R1 stated he/she ordered M1 from store and hid in the room but did not tell any staff. R1 did not want to reveal where he/she hid M1.

LPA interviewed Director of Assisted Living (S1). S1 stated he/she received a phone call from the hospital nurse on 11/14/2025 that R1 had several sleeping medication M1 pills per day for several days. S1 stated R1 had doctor prescription medication M1 one pill per day as needed at bedtime. S1 stated the facility did not know R1 ordered M1 online. S1 stated the facility does not open resident's package without resident's permission because of privacy rights. S1 stated on 11/17/20205 FM came to R1's room and removed medication M1 from the room and closed R1's Amazon account.

LPA interviewed staff S2. S2 stated R1 had prescription PRN medication M1 one pill per day at night. S2 stated the facility only gave M1 one pill at night per day when R1 requested.
Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20251118163955

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: 12/30/2025

NARRATIVE

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S2 stated he/she never saw R1 had his/her own medication M1. S2 stated he/she never saw M1 left in R1's room.

LPA interviewed 2 caregivers. Both stated they did not administer medication to R1 and did not see any medication M1 in R1's room.

Based on the review of R1's doctor order, R1's had prescription medication M1 one pill per day as needed at bedtime, and was stopped on 11/17/2025.

Based on the review of R1's Medication Administration Records, a 25 mg M1 pill was administered to R1 on 11/01/2025 to 11/06/2025, and 11/08/2025 to 11/12/2025.

Based on the review of the incident report, on 11/21/2025, the facility conducted a room search for R1's room by Director of Assisted Living and Med Tech, a bottle of medication M1 was found under the mattress. The bottle of M1 was removed from the room. R1 was sent to hospital for evaluation. R1 was sent to skilled nursing Rehabilitation facility.

The department has investigated the above allegation. Based on the observations, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with BD. A copy of this report was provided to BD.

Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025

LIC9099 (FAS) - (06/04)

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