435202665-4-4-2025-26-AS-KHOS-DGMJ6Y-20250513064707

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202665
Report Date: 04/04/2025
Date Signed: 04/04/2025 04:14:35 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
03/20/2025 and conducted by Evaluator Christine Kabariti

COMPLAINT CONTROL NUMBER: 26-AS-20250320085458

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: 78	DATE:	04/04/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Eugenia Smith		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff mishandled a resident's medication while in care

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the findings regarding the above allegations. LPA met with Executive Director, Eugenia Smith.

On 03/20/2025, the Department received the complaint. On 03/27/2025, the initial complaint investigation was conducted.

The following documents were obtained to include: resident rosters, staff schedule from January – March 2025, resident (R1)’s physician’s reports, needs and services plan, medication administrator record from January – March 2025, med tech communication notes, progress notes from January – March 2025, medical records, physician communication records, outside agency documentation, and the private caregivers shift notes. Page 1 of 2.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

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 6

Control Number 26-AS-20250320085458

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: 04/04/2025

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

It was alleged that staff mishandled a resident (R1)’s medication the morning of 02/07/2025. It was stated that on 02/07/2025 around 7:00am, R1’s private caregiver requested a PRN medication for R1 due to increased coughing, but the medication was not administered until around 10:00am.

Based on staff interview, it was stated that the NOC shift MedTech administered the PRN cough medicine around 6:00am, which was why the staff waited until 10:00am to give the next dose. Staff stated that they needed to wait until 4 hours had passed (per the physician’s order) before administering the next dose of the PRN cough medication.

Based on record review of R1’s PRN log, on 02/07/2025 the 6:00am dose of PRN cough medicine was not recorded in R1’s PRN log. It was only recorded that R1 was administered the cough medicine at 10:12am the morning of 02/07/2025. The prior dose recorded was from 02/06/2025 at 8:27pm.

The facility provided a written communication note on 02/07/2025 between MedTechs, which noted that R1 was administered a PRN medicine for cough at 6:00am, however, this note did not include the dosage and effectiveness of the medication.

The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D.

This report was reviewed with Executive Director, Eugenia Smith and Generations Program Director Erin Wiley and a copy of the report and appeal rights was provided.

Page 2 of 2.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20250320085458

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: 04/04/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/05/2025 Section Cited CCR 87465(c)(3)	1 2 3 4 5 6 7	(c) ... facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.	1 2 3 4 5 6 7	Licensee will provide an in-service training with all medtechs (AM, PM, and NOC). Licensee will submit the facility's plan to complete the training along with training topics to LPA Kabariti by POC due date of 04/05/25.
	8 9 10 11 12 13 14	Based on interview, record review and observation the licensee did not comply with the section cited above wherein the licensee did not ensure a record of R1’s PRN medication on 02/07/2025 at 6:00am was recorded, to include the dosage taken and resident’s response which poses/posed a potential health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14	Once training is completed, licensee will submit the in-service training documents to LPA Kabariti.
	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.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
03/20/2025 and conducted by Evaluator Christine Kabariti

COMPLAINT CONTROL NUMBER: 26-AS-20250320085458

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:	DATE:	04/04/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Eugenia Smith		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained an unexplained injury while in care
Staff did not provide adequate care and supervision of a resident

INVESTIGATION FINDINGS:

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

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20250320085458

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: 04/04/2025

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

It was alleged that on 01/25/2025, resident (R1) sustained an unexplained spinal fracture injury while in care. During R1’s hospital visit, R1 was diagnosed with a viral infection and spine fracture. It was unclear whether the spinal fracture was caused by an unwitnessed fall that was not reported by the facility or due to symptoms of the viral infection.

6 staff members were interviewed. Based on staff interview, 6 out of 6 staff stated that R1 was a fall risk. 5 out of 6 staff did not observe R1 sustain a fall and was not informed of a fall that R1 had sustained during their shift and prior to their shift. 1 out of 6 staff stated they believe R1 had a fall, which is how R1 sustained a spine fracture, however, this staff could not provide more details to include when and where the fall occurred. This staff stated that if there was a fall, it should have been documented in R1’s chart.

Based on record review, there was no indication in R1's notes that R1 had sustained a fall prior to R1’s hospital visit on 01/23/2025. It was only noted that R1 wasn’t feeling well and complained of chest pain and coughing, in where R1 was taken to the emergency room. The review of R1’s medical records did not indicate how R1 sustained the spinal fracture. R1 is diagnosed with a health condition related to weak bones.

A witness was interviewed, who was unsure how R1 sustained the spinal fracture.

It was alleged that staff did not provide adequate care and supervision due to an incident that occurred on 02/26/2025. On 02/26/2025, a witness (W1) observed R1 bent over, pulling a heavy chair in the common area and there was no staff member in sight. It was stated that the facility was instructed by R1’s family member to ensure R1 is in sight of the caregivers 24/7.

Based on record review, the facility was not providing 1:1 care for R1 during the day time. R1’s service plan indicated status checks for 4-6x a day.

Page 2 of 3.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 26-AS-20250320085458

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: 04/04/2025

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

It was noted that staff are to make frequent checks for resident’s safety and to assist the resident during transitions from activities, meals, and back to the apartment. The service plan did not indicate a time frame of how often staff should be checking on the resident.

A witness (W1) was interviewed. Based on interview, around 5:30pm W1 did not observe staff supervising the residents in the common area when R1 was bent over with a back brace pulling a heavy chair. W1 denied calling a staff for assistance or looking for a staff after the observation of the incident. W1 states there are usually around 2-3 staff working in memory care.

5 staff members were interviewed regarding this allegation. Based on staff interview, the caregivers check in on R1 very frequently if R1 is in his/her bedroom alone. It’s stated that R1 is normally in the common area during the day to allow for staff to observe R1 closely. Staff stated the facility has at least 3-4 caregivers, 1 medtech, and 1 activities staff working the morning shift; 3-4 caregivers and 1 medtech for the afternoon/evening shift; and 3 caregivers and 1 medtech during the NOC shift.

Based on review of the facility’s staffing schedule in memory care, the facility has at least 3 – 4 caregivers and 1 MedTech scheduled in the morning and afternoon shift, and at least 2 caregivers and 1 MedTech during the NOC shift.

The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicated that although the allegation may have happened and/or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

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

Page 3 of 3.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 6