435202665-10-29-2021-26-AS-KHOS-CM65CR-20221215185044

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 10/29/2021
Date Signed: 10/29/2021 01:50:21 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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

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: 63	DATE:	10/29/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Jennifer Bruhn		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained multiple fractures while in care
Staff failed to seek medical attention for resident in a timely manner

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced visit to deliver findings of the above allegations and met with Executive Director, Jennifer Bruhn.
On 05/11/2021, during tele-visit, LPA Karen Taku requested the following documents from the facility to include staff and resident roster, staff training logs, and 6 resident files.

Based on review of R1's medical records, R1 suffered rib fractures and had a possible fracture of the right elbow.

An interview with the facility Administrator found, R1 was diagnosed with a neurocognitive disorder. R1 had multiple witnessed and unwitnessed falls. R1 had a walker to aid with mobility but most of the time R1 refused to use it.

Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

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-20210511092104

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LOMA CLARA SENIOR LIVING	FACILITY NUMBER: 435202665
	VISIT DATE: 10/29/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facility staff encourage R1 to use the walker on a regular basis and to ask for assistance, but R1 did not ask for assistance and attempted to do what R1 wanted without assistance.

An interview with R1's responsible party (RP) / health care agent was aware of R1's neurocognitive disorder and its symptoms. RP stated R1 was reassessed on 04/11/2021 wherein R1 was identified as a fall risk. R1's plan of care was that staff will provide occasional reminders and cueing due to memory loss. Staff were expected to observe for proper footwear and assure pathways are clutter free, items of necessity are within reach with adequate lighting, and frequent status checks of R1. R1 was encouraged to request assistance when needed, and to use walker at-all-times.

Due to R1's neurocognitive disorder, the department was unable to obtain any information from R1.

Staff failed to seek medical attention for resident in a timely manner.

Alleged that the facility staff did not take R1 to the hospital when R1 had complained of pain after a fall in May 2021. R1 was evaluated by Staff (S1), a non-medical professional. R1 was taken to the hospital four days after R1's fall because R1's health care agent did not want to send R1 to the hospital.

An interview with R1's responsible party (RP) stated awareness of R1's fall. RP stated that due to R1's neurocognitive disorder, R1 has lost the ability to articulate and therefore cannot express possible pain. RP stated that R1 did not complain of pain in between his fall on 05/06/2021 and the day R1 went to the hospital on 05/09/2021.

Staff (S1) was interviewed who assessed R1. S1 stated that on 05/06/2021, R1 told S1 that R1 had fallen and gotten up without assistance. R1 denied any pain and hitting head. R1 was assessed for injuries and observed a cut on right elbow wherein it was cleaned and bandaged. R1's vital signs were taken within normal limits.

Page 2 of 3.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LOMA CLARA SENIOR LIVING	FACILITY NUMBER: 435202665
	VISIT DATE: 10/29/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff (S2) was interviewed. S2 stated interaction with R1 on 05/06/2021 but R1 did not complain of pain. S2 stated that on 05/09/2021, R1 complained of pain on R1's right side wherein R1 was given pain medication. R1 was monitored throughout the day. RP then later decided to take R1 to the hospital due to increase agitation.

Staff (S3) was interviewed. S3 documented that R1 complained of slightly sore ribs, and no noted bruising or redness to the area. Pain medication was administered to R1, although R1 did not indicate how R1 was feeling.

Staff (S4) was interviewed. S4 stated contacting RP on 05/05/2021 regarding fall. R1 had complained of minimal pain and had no visible injuries. S4 states 911 was not called as directed by R1’s health care agent.

The Department has investigated the above allegations. Based on interviews conducted and records reviewed, the Department found 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 that the allegations did or did not occur.

This report was reviewed with Executive Director, Jennifer Bruhn and a copy provided.

Page 3 of 3.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3