435202710-3-17-2022-26-AS-KHOS-CCSNTW-20220323104525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202710
Report Date: 03/17/2022
Date Signed: 03/17/2022 03:33:52 PM

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
03/10/2022 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20220310160836

FACILITY NAME:	VILLAS AT SARATOGA SKILLED NURSING & ASST LVG, THE		FACILITY NUMBER:	435202710
ADMINISTRATOR:	WILLIAMS, RYAN		FACILITY TYPE:	740
ADDRESS:	20400 SARATOGA LOS GATOS RD		TELEPHONE:	(408) 741-2950
CITY:	SARATOGA	STATE: CA	ZIP CODE:	95070
CAPACITY:	74	CENSUS: 31	DATE:	03/17/2022
		UNANNOUNCED	TIME BEGAN:	01:44 PM
MET WITH:	Travis Clawson		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff hit a resident while in care

INVESTIGATION FINDINGS:

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On 03/17/2022 at 01:44 pm, Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced initial 10-day complaint investigation regarding the above allegation. LPA met with Travis Clawson, Administrator (Admin).

During today’s visit, LPA interviewed 1 staff member (Admin) and requested documents. Admin stated that there have been no residents from Assisted Living that have complained about the allegation listed above. Admin confirmed that the alleged victim (R1) has never been a resident of the facility’s assisted living side but is a resident of the skilled nursing facility (SNF).

-Continued, see LIC 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20220310160836

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: VILLAS AT SARATOGA SKILLED NURSING & ASST LVG, THE	FACILITY NUMBER: 435202710
	VISIT DATE: 03/17/2022

NARRATIVE

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During review of facility's admission records, LPA confirmed that R1 had no admission history in the facility's assisted living wing. LPA further confirmed via admission records that R1 had been residing in the skilled nursing wing of the facility for over 5 years. LPA confirmed that R1 was not and had never been a resident of the facility’s Assisted Living building. Suspected Abuser (SA) was also confirmed to not have worked in the assisted living facility.

This facility is a Residential Care Facility for the Elderly which contains both an Assisted Living (AL) and Skilled Nursing Facility (SNF). SNF is regulated by the Department of Public Health.

The Department has investigated the above allegation. Based on interviews conducted and documents reviewed, the Department found the above allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited during today’s visit.

Exit interview was conducted with Travis Clawson, Administrator. This report was reviewed with Travis Clawson, Administrator, and a copy was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022

LIC9099 (FAS) - (06/04)

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