435202666-12-21-2023-26-AS-KHOS-D45PZR-20240408114557

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202666
Report Date: 12/21/2023
Date Signed: 12/21/2023 04:46:41 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
12/15/2023 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20231215141202

FACILITY NAME:	TOUCH OF LIFE RESIDENTIAL CARE FACILITY INC		FACILITY NUMBER:	435202666
ADMINISTRATOR:	DEVANO, BELINDA		FACILITY TYPE:	740
ADDRESS:	2748 ASHLEY CT		TELEPHONE:	(408) 854-0735
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	6	CENSUS: 3	DATE:	12/21/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Belinda Devano		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff do not communicate with responsible party regarding resident's care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) David Marrufo and Maria (Mita) Partoza conducted an unannounced complaint investigation and met with Administrator (ADM) Belinda Devano.

LPAs obtained copies of text messages between administrator and resident R1's Responsible Party RP1. On November 24, 2023 administrator notified RP1 about R1s vaccination appointment. On December 4, 2023, ADM texted RP1 a photo of the COVID-19 consent form requesting RP1s signature. On December 12, 2023 RP1 texted ADM regarding why hospice has not given RP1 any update from the hospice agency. ADM responded asking if ADM can call RP. ADM provided RP1 the contact from the hospice agency via text on the same day. On December 13, 2023 RP1 requested ADM to email the visitor log when vistor came to see R1.

See LIC9099-C for more information - page 1 of 3

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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-20231215141202

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: TOUCH OF LIFE RESIDENTIAL CARE FACILITY INC	FACILITY NUMBER: 435202666
	VISIT DATE: 12/21/2023

NARRATIVE

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LPAs obtained a copy of ADMs email to RP1 sent on December 14, 2023 with an attachment of the visitor log as requested by RP1.

On Monday, December 18, 2023 RP1 texted ADM that R1 will be removed from the facility and to send all clothes, medication and instruction with R1.

LPAs obtained the following documents from ADM. Handwritten inventory of R1s personal clothing items signed in behalf of R1s POA by the ambulance staff who ADM stated picked up R1 from the facility to transport R1 to the new facility.

LPAs obtained a handwritten medication release form of R1's medication dated 12/19/23 at 10:00 a.m. The document listed all medications and says to "see label" for instruction for each medication. The document is signed by someone that ADM stated was the ambulance staff who came to pick up R1 to transport R1 to the new facility. LPAs obtained an additional document with R1's medication list with instruction dated 12/19/2023 and signed by ADM and by the ambulance staff.

LPAs obtained a copy of ADMs cellphone call log. ADM had telephone calls with RP1 on the following dates: 12/12/23, 12/13/23, 12/15/23 (missed call), 12/15/23 2:55 p.m. incoming call (IC). 12/15/23 4:53 p.m. outgoing call (OC), 12/15/23 6:39 p.m. (IC), 12/17/23 1:53 p.m. (OC), 12/17/23 2:01 p.m. (IC), 12/19/23 10:03 a.m. (OC).

During interview ADM stated that there was no agreement between and ADM and RP1 to regularly update RP1 regarding R1's even if there was no change in R1's condition. ADM stated during interview that R1 did not have any change in condition while at the facility. During interview, ADM stated that when RP1 texted ADM asking why hospice had not contacted RP1 for 4 weeks, ADM stated that ADM has no control over when hospice agencies call responsible parties. ADM stated ADM gave RP1 the hospice contact information.

LPAs conducted a telephone interview with R2's Responsible Party (RP2). During interview RP2 stated ADM communicates with RP2 regarding R2s care.

See LIC9099-C for more information
page 2 of 3

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20231215141202

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: TOUCH OF LIFE RESIDENTIAL CARE FACILITY INC	FACILITY NUMBER: 435202666
	VISIT DATE: 12/21/2023

NARRATIVE

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LPAS attempted to interview Responsible Parties for R3 and R4 but were only able to leave a voicemail and requested for a return call.

Based on information from interviews conducted with ADM and Responsible Parties, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

This report was reviewed with administrator Belinda Devano and a copy of the report was provided.

page 3 of 3 end report

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3