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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202710
Report Date: 03/18/2022
Date Signed: 03/18/2022 11:58:32 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2020 and conducted by Evaluator Marybeth Donovan
COMPLAINT CONTROL NUMBER: 26-AS-20201026105610
FACILITY NAME:VILLAS AT SARATOGA SKILLED NURSING & ASST LVG, THEFACILITY NUMBER:
435202710
ADMINISTRATOR:WILLIAMS, RYANFACILITY TYPE:
740
ADDRESS:20388 SARATOGA LOS GATOS RDTELEPHONE:
(408) 741-2950
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:74CENSUS: 31DATE:
03/18/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Travis Clawson AdministratorTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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9
Facility staff not responding to residents call button.
Staff left resident in soiled clothing.
Staff left resident in soiled diaper.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the findings to the above allegations. LPA met with Travis Clawson Administrator.

S1 was interviewed. S1 was not aware of any residents left in soiled clothing or diaper for a long period of time, and staff not responding to residents call button.

W1 was interviewed. W1 stated concerns of neglect occurred when R1 was living in the skilled nursing facility. R1 was never a resident in assisted living.

SN1 was interviewed. SN1 stated R1 was a resident in the skill nursing facility and R1 was never a resident in assisted living. Resident roster was reviewed and did not indicate R1 as a resident in assisted living.

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Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
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 2
Control Number 26-AS-20201026105610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VILLAS AT SARATOGA SKILLED NURSING & ASST LVG, THE
FACILITY NUMBER: 435202710
VISIT DATE: 03/18/2022
NARRATIVE
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The Department has investigated the above allegations. Based on interviews conducted and documents reviewed, the Department found the above allegations to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

The report was reviewed with Travis Clawson and a copy of this report provided.



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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2