435202665-12-1-2022-26-AS-KHOS-CM65CQ-20221215185043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 12/01/2022
Date Signed: 12/01/2022 04:46:33 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
05/11/2021 and conducted by Evaluator Christine Dolores

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210511092104

FACILITY NAME:	LOMA CLARA SENIOR LIVING		FACILITY NUMBER:	435202665
ADMINISTRATOR:	JOLIE C. HIGGINS		FACILITY TYPE:	740
ADDRESS:	16515 BUTTERFIELD BLVD		TELEPHONE:	(669) 258-3500
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	89	CENSUS: 65	DATE:	12/01/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jett Cabuena		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Staff mismanages residents’ medications
Staff handles resident in a rough manner
Staff failed to follow residents’ prescribed diet plans
Staff steals residents’ personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the remaining findings for the above allegations. LPA met with Executive Director, Jett Cabuena.

On 05/11/2021, LPA Karen Taku conducted the initial investigation virtually due to suspended on-site visits during the pandemic. The following documents were obtained during the initial investigation to include the facility’s staff roster, resident roster, training logs, R1 – R6 resident files.

From 08/08/2022 – 12/01/2022, LPA Dolores continued the investigation. LPA interviewed 5 out of 6 staff members and 5 out of 5 residents. Additional documents were obtained to include resident’s physician report, needs and services plan, progress notes, safeguard of personal property / valuables form, staff schedule and resident roster from May 2021 and August 2022.

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Unsubstantiated

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: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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-20210511092104

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: 12/01/2022

NARRATIVE

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Based on record review and interview, as of August 2022 the residents being investigated are no longer resides at the facility.

Staff mismanages residents’ medications

From 08/08/2022 – 08/11/2022, 5 out of 5 staff members were interviewed. 3 out of 5 staff members interviewed were familiar with medication management. 2 out of 5 staff members do not handle medications. 1 out of the 2 staff members does not provide direct resident care and was not asked questions regarding the allegation.

4 out of 4 staff have never observed staff pre-pour medications. 3 out of 4 staff have never observed medications on the floor. 1 out of 4 staff has observed medication on the floor. Staff state to follow the facility’s procedures after they observe medication on the floor.

From 08/08/2022 – 12/01/2022, 5 out of 5 residents were interviewed. 4 out of 5 residents states to have never seen medications on the floor. 4 out of 5 residents state the staff has not mismanaged their medications. 1 out of 5 residents was not able to answer the interview questions.

Staff handles residents in a rough manner

From 08/08/2022 – 12/01/2022, 5 out of 5 residents were interviewed. 5 out of 5 residents state to have not been handled in a rough manner nor have staff forced them to do anything. 5 out of 5 residents stated positive feedback towards facility’s staff.

Staff failed to follow residents’ prescribed diet plans

On 08/08/2022, 5 out of 5 staff members were interviewed. 5 out of 5 staff members were not aware of staff failing to follow residents prescribed diet plans. Based on interviews, the facility has a dietary communication form that goes to the kitchen, which will show if the resident has a special diet. All food being given to the residents are prepared in the facility’s kitchen by the facility’s culinary service director. PAGE 2 OF 4.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20210511092104

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: 12/01/2022

NARRATIVE

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S3 state residents in memory care who have a special diet such as puree or mechanical soft will be indicated on a paper posted on the refrigerator.

1 out of 5 staff state to serve different kinds of alternative desserts for resident’s who are diabetic. The facility’s kitchen staff has a binder indicating every resident’s information to include special diet, allergies, etc. S4 states to know what kind of food is being served to the resident and ensure to do rounds to check if the residents are being served proper food.

From 08/08/2022 to 12/01/2022, 5 out of 5 residents in were interviewed. 5 out of 5 residents does not have a special diet. 5 out of 5 residents are not given foods with too much sugar that would cause any medical concerns.

Based on observation, the facility has a special diet board to include the residents name, picture, and type of special diet (puree or mechanical soft) posted on the refrigerator.

Staff steals residents’ personal belongings

On 08/08/2022, 5 out of 5 staff members were interviewed. 1 out of the 5 staff members does not provide direct resident care and was not asked questions regarding the allegation.

4 out of 4 staff members has not observed staff steal a resident’s personal belongings. Staff state sometimes the residents have behaviors of taking other resident’s personal belongings and placing them elsewhere. S2 state a staff member had to place a resident’s personal belongings in the facility’s activity closet due to behaviors to putting their clothing anywhere else but the resident’s room.

From 08/08/2022 – 12/01/2022, 5 out of 5 residents were interviewed. 5 out of 5 residents have not observed staff steal their personal belongings.

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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: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20210511092104

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: 12/01/2022

NARRATIVE

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Based on observation, the facility’s Janitor closet contained items not limited to clothing, walkers, and diapers. S1 state the clothing in the janitor closet are from resident’s who have passed away, in which the family would like to donate. The diapers are for residents who have behaviors in tearing them apart, misplacing them, overstock, or are donated. LPA observed some items in the closet labeled with the resident’s name and room number, if they belong to a resident.

The Department has investigated the above allegations. Based on interviews, records review, and observation the Department has determined that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that 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.

No deficiencies are being cited per California Code of Regulations, Title 22.

This report was reviewed with Executive Director, Jett Cabuena 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: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4