435202684-4-16-2024-26-AS-KHOS-D4KNGV-20240422102747

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202684
Report Date: 04/15/2024
Date Signed: 04/16/2024 08:08:00 AM

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
08/03/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220803135933

FACILITY NAME:	MOMENTUM FOR MENTAL CRISIS RESIDENTIAL		FACILITY NUMBER:	435202684
ADMINISTRATOR:	ALBERT CARRASCO		FACILITY TYPE:	772
ADDRESS:	101 JOSE FIGURES		TELEPHONE:	(408) 254-6828
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	16	CENSUS: 15	DATE:	04/15/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Christina Rossi		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Illegal Eviction.
Resident was not being accorded dignity.
Staff forced resident to take medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with administrator (ADM) Christina Rossi.

On 08/03/2022, the Department received a complaint with the above allegations.

On 08/11/2022, the Department conducted an initial investigation. LPA interviewed 2 staff and requested client physician report, program discharge form, Admission Agreement, Clinical Admission Summary, and Policy for Client refuses Medication, R1's property inventory, and Residential Medication Procedures.

On 01/27/2023, LPA interviewed 3 facility staff and toured the storage room for the left residents' belongings.

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: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

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 5

Control Number 26-AS-20220803135933

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: MOMENTUM FOR MENTAL CRISIS RESIDENTIAL	FACILITY NUMBER: 435202684
	VISIT DATE: 04/15/2024

NARRATIVE

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Illegal Eviction:
On 08/11/2022, LPA interviewed Administrator (ADM) Christina Rossi. ADM stated client C1 was admitted to the program on 7/26/22 and left the program on 08/01/2022. ADM stated the facility did not force C1 to leave. ADM stated C1 mentioned he/she did not want to continue the program. The facility asked C1 to sign a document if C1 would not finish the program. C1 signed the document on 08/01/2022. ADM stated on 08/01/2022, C1 left the program and the facility without notice to the facility staff.

On 8/11/2022 and 01/27/2023, LPA interviewed staff S1 and S2. Both stated client C1 left the program and the facility by himself/herself. Both stated the facility did not force C1 to leave.

The facility Director of Licensing and Regulation provided a copy of the letter/document that C1 was leaving the program against the advice of the attending physician and the program administrator which was signed by client C1 on 8/1/2022.

No evidence to indicate that client C1 was forced to leave the program and the facility.

Resident was not being accorded dignity:
Staff forced resident to take medication:
On 8/11/2022, LPA interviewed staff S1. S1 stated he/she explained to client C1 what the medications was for when he/she administered medications to C1. S1 stated he/she never told C1 the medications were for "hearing voices".

On 1/27/2023, LPA interviewed staff S3, S3 stated he/she administered medications to R1 by having R1 to be in the Med room. S3 stated if C1 refused to take medications, he/she will try 3 times to administer medications to R1 by calling R1 to be in the Med room within 2 hours. If clients refuse medications for longer than 2 hours, staff will document client "refuse medication". S3 stated he/she will document in the Medication Administration Records. S3 stated he/she never forced C1 to take the medications. S3 stated if S3 did not take the medication, then he/she reported to Administrator.

S2 stated the facility staff tried to convince C1 to take the medications but never forced C1 to take the medication.
Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20220803135933

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: MOMENTUM FOR MENTAL CRISIS RESIDENTIAL	FACILITY NUMBER: 435202684
	VISIT DATE: 04/15/2024

NARRATIVE

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LPA interviewed ADM. ADM stated the facility staff are trained to treat clients with dignity. ADM stated the facility staff are trained how to deal with the clients who does not want to take medications. ADM stated the facility staff won't force the clients to take medications.

No evidence to indicate that the facility staff forced C1 to take medications, and no evidence to indicate the facility staff treated C1 without dignity.

The department has investigated the above allegations. Based on the investigation, 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 citation noted today. The report was provided to ADM for signature. A copy of the report was provided to ADM.

Page 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5