435202725-8-14-2024-26-AS-KHOS-D8JQYP-20240827123527

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202725
Report Date: 08/14/2024
Date Signed: 08/14/2024 11:14:40 AM

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
07/13/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230713135124

FACILITY NAME:	WILLOW GLEN SENIOR LIVING		FACILITY NUMBER:	435202725
ADMINISTRATOR:	PAMELA D. PERALTA		FACILITY TYPE:	740
ADDRESS:	2991 FAIRCLIFF CT		TELEPHONE:	(408) 914-1147
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	6	CENSUS: 5	DATE:	08/14/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Irish Ladwig		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Facility staff are not meeting the needs of the resident
Private care givers administer medications to resident
Facility is in disrepair
Facility water temperature is too hot
Facility is not following resident's admission agreement

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding for the above allegations. LPA met with Licensee Irish Ladwig.

On 07/13/2023, the Department received the complaint. On 07/19/2023, the initial complaint investigation was conducted.

The following documents were obtained to include the, LIC500, sample menu, water heater invoice, email correspondences, text message exchanges, R1’s admission agreement, pre-placement appraisal, appraisal/needs and services plan, physician’s report, centrally stored medication record, sitter & companion role and responsibilities and other resident records.
PAGE 1 OF 6.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

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 13

Control Number 26-AS-20230713135124

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: WILLOW GLEN SENIOR LIVING	FACILITY NUMBER: 435202725
	VISIT DATE: 08/14/2024

NARRATIVE

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Facility staff are not meeting the needs of the resident
It was alleged that the facility staff are not meeting the needs of the residents due to resident (R1)’s private caregiver providing all activities of daily living (ADL) care to include showers, dressing, transportation to medical appointments, and medication administration.

Based on review of R1’s needs and services plan, it’s indicated the facility will provide assistance as needed e.g. positioning, ambulation, toileting, feeding, dressing, bathing, way-finding, encourage daily physical activities such as walking, schedule daily walks, give medications as needed, and perform regular intentional rounding to assess need for position change, pain assessment, and personal needs such as toileting.

Based on review of R1’s signed admission agreement, R1 was paying a monthly fee for “total care: personal full assistance with ADLs…” and “basic services”. The facility’s basic services includes, “assistance with bathing, dressing, grooming, toileting, eating, continence, transferring from bed or chair, and other personal needs”.

Throughout the course of this investigation, 6 residents, 4 staff, and 1 witness was interviewed.

Based on interview with R1’s private caregiver (W1), it was stated that W1 assists R1 with dressing, bathing, hygiene, grooming, daily activities like walks, and appointments. W1 states the facility’s caregivers dispenses R1’s medication and W1 gives the medication in a cup to R1. W1 states the facility’s caregivers does the laundry and cleans R1’s room.

Based on staff interview, 4 out of 4 staff confirmed that R1 has a private caregiver during the day that assist R1 with his/her activities of daily living (ADL) care to include dressing, bathing, toileting, and activities. 4 out of 4 staff state that the facility’s staff only assists the resident during the night. During the day, the facility’s staff assists only with dispensing medications, meals, laundry, and cleaning.
PAGE 2 OF 6.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

Page: 11 of 13

Control Number 26-AS-20230713135124

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: WILLOW GLEN SENIOR LIVING	FACILITY NUMBER: 435202725
	VISIT DATE: 08/14/2024

NARRATIVE

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Based on interview with the Administrator on 07/19/2023, it was states that the facility staff manages the medications, prepares the food, does laundry, and clean R1’s room. ADM stated that R1’s 1:1 caregiver does “everything” and the facility staff helps out when R1’s 1:1 private caregiver goes on break.

On 02/09/2024, the Administrator (ADM) was re-interviewed. Based on interview, it was stated that due to the time it took to assist R1 with activities such a walking, walking to a coffee shop, and to medical appointments they started the topic of a private caregiver for R1’s safety. The private caregiver was like a companionship. ADM stated that the facility’s staff are responsible for ADL care to include showers, grooming, and toileting. It was stated that at that time, there was confusion on the facility staff and private caregivers’ responsibilities.

Private care givers administer medications to resident
It was alleged that R1’s private caregivers will get the cup of medication and administer R1’s medications.

Throughout the course of this investigation 4 staff, and 1 witness was interviewed.

Based on interview with R1’s private caregiver (W1), it was stated the facility’s caregivers dispenses R1’s medication and W1 gives the medication in a cup to R1.

Based on staff interview, 4 out of 4 staff state R1’s private caregiver administers R1’s medications. S1 states R1’s private caregiver asks for permission to get R1’s medication cup and will give it to R1. S4 stated when dispensing R1’s medication they dispense the medication in the cup then hand it over to the personal caregiver. Staff then checks on R1 to make sure R1 take his/her medication.

Based on interview with the Administrator and Licensee, it was stated that the private caregiver did administer the medication to R1 and that it did happen. Licensee states R1's private caregiver is trained on medication administration.
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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

Page: 10 of 13

Control Number 26-AS-20230713135124

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: WILLOW GLEN SENIOR LIVING	FACILITY NUMBER: 435202725
	VISIT DATE: 08/14/2024

NARRATIVE

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Facility is in disrepair
It was alleged that the facility is in disrepair as there was only one shower available for the residents and staff to use in the home. It was also alleged that the bathroom near R1’s bedroom had a hole on the left side of the toilet, and the bathroom fan was dysfunctional.

On 07/19/2023, LPA Dolores toured the facility and observed the bathroom shower located in the hallway contained a large chair and boxes. Based on staff interview, it was stated that the shower was not in use because it is in disrepair. It was stated that all residents and staff used the shower near R1’s bedroom. On 01/24/2024, LPA Monter toured the facility and observed the bathroom shower located in the hallway was fixed.

Based on review of the photographs obtained, it shows the bathroom near R1’s bedroom contained a hole behind the left side of the toilet. The photo also shows the lid of the fan was placed on top of the toilet. It was stated that the fan was replaced by the Licensee. Based on interview, R1’s responsible party voluntarily hired a contractor to fix the hole behind the toilet.

Facility water temperature is too hot
It was alleged that the facility’s water temperature is too hot.

On 07/19/2023, LPA Dolores measured the hot water temperature near R1’s bedroom. The hot water temperature was measured at 125 degrees Fahrenheit.
On 07/19/2023, the Administrator was interviewed. Based on interview, it was stated that they had an issue with the water heater and shower. It was stated that they hired a plumber who came to the facility 2 weeks ago. It was stated that sometimes the staff doesn’t tell the Administrator right away, when things are broken.
On 01/24/2024, LPA Monter measured the hot water temperature near R1’s bedroom. The water temperature rose to 125 degrees Fahrenheit then dropped to 100 degrees Fahrenheit. Staff stated it might be due to the washing machines currently running.
On 02/09/2024, LPA Dolores measured the hot water temperature to be maintained at 130 degrees Fahrenheit.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

Page: 13 of 13

Control Number 26-AS-20230713135124

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: WILLOW GLEN SENIOR LIVING	FACILITY NUMBER: 435202725
	VISIT DATE: 08/14/2024

NARRATIVE

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Facility is not following resident's admission agreement
It was alleged that the facility is not following R1’s admission agreement as the facility did not provide R1 with basic services to include hygiene items, weekly laundry, cleaning of R1’s room, assistance for transportation to appointments, and activity of daily living (ADL) care. It was alleged that R1’s private caregiver assisting R1 with bathing assistance, dressing assistance, tray for meals, changing, brushing of teeth, providing R1’s responsible party with updates, and medication administration.

Based on review of R1’s signed admission agreement, it’s stated that the licensee will provide the resident with basic services to include (but not limited to): hygiene items or general use of such soap and toilet paper; plan/arrange/and/or provide for basic transportation to medical and dental appointment; assistance with bathing, grooming, toileting, eating, continence, transferring from bed or chair, and other personal needs; assistance in meeting necessary medical and dental needs; assistance with taking prescribed and over-the-counter medications.

Throughout the course of this investigation, 6 residents, 4 staff, and 1 witness was interviewed.

Based on interview with R1’s private caregiver (W1), it was stated that W1 assists R1 with dressing, bathing, hygiene, grooming, daily activities like walks, and appointments. W1 states the facility’s caregivers dispenses R1’s medication and W1 gives the medication in a cup to R1. W1 states the facility’s caregivers does the laundry and cleans R1’s room.

Based on staff interview, 4 out of 4 staff confirmed that R1 has a private caregiver during the day that assist R1 with his/her activities of daily living (ADL) care to include dressing, bathing, toileting, and activities. 4 out of 4 staff state that the facility’s staff only assists the resident during the night. During the day, the facility’s staff assists only with dispensing medications, meals, laundry, and cleaning.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

Page: 12 of 13

Control Number 26-AS-20230713135124

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: WILLOW GLEN SENIOR LIVING	FACILITY NUMBER: 435202725
	VISIT DATE: 08/14/2024

NARRATIVE

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Based on interview with the Administrator on 07/19/2023, it was states that the facility staff manages the medications, prepares the food, does laundry, and clean R1’s room. ADM stated that R1’s 1:1 caregiver does “everything” and the facility staff helps out when R1’s 1:1 private caregiver goes on break.

On 02/09/2024, the Administrator was re-interviewed. Based on interview, R1’s private caregiver’s role was to provide companionship as R1 was a high fall risk due to his/her medical condition. It was stated that there was initially confusion with staff and the private caregiver of their roles and responsibilities.

The Administrator states the facility provides basic hygiene items, however, the resident's and/or resident's responsible parties may provide their own if there are specific brands they prefer. It was stated that R1's responsible party wanted to take R1 to medical appointments and sometimes the private caregiver would take R1 to R1's medical appointment and meet with R1's responsible party.

During the initial investigation on 07/19/2023, there was no written agreement or contract that was produced to differentiate the responsibilities of the facility staff and private caregiver.

Based on record review, on 08/23/2023 a “sitter & companion role and responsibilities” contract was written showing the breakdown of duties for caregivers and the private care giver.

The Department has investigated the above allegations. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegations are SUBSTANTIATED.

Deficiencies were cited per California Code of Regulations, Title 22. LIC9099-D.

This report was reviewed with Licensee, Irish Ladwig and a copy of the report and appeal rights were provided.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

Page: 9 of 13

Control Number 26-AS-20230713135124

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: WILLOW GLEN SENIOR LIVING	FACILITY NUMBER: 435202725
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/15/2024 Section Cited CCR 87464(a)	1 2 3 4 5 6 7	(a) The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care. Such persons shall be encouraged to participate as fully as their conditions permit in daily living activities both in the facility and in the community. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee has corrected their deficiency prior to visit by completing a sitter & companion role and responsibilities contract in collaboration with R1's family member.
	8 9 10 11 12 13 14	Based on interview, record, and observation the licensee did not ensure the facility staff provided basic services to include ADL care to resident (R1) which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
Type A 08/15/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee has corrected their deficiency prior to visit by completing a sitter & companion role and responsibilities contract in collaboration with R1's family member.
	8 9 10 11 12 13 14	Based on interview, the licensee did not ensure to assist R1 with self-administration of medication as R1’s private caregiver was administering R1’s medication which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 13

Control Number 26-AS-20230713135124

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: WILLOW GLEN SENIOR LIVING	FACILITY NUMBER: 435202725
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/15/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was met as evidenced by:	1 2 3 4 5 6 7	Licensee has already corrected the deficiency prior to visit by repairing the bathroom shower in the hallway and items that were in disrepair near R1's bedroom.
	8 9 10 11 12 13 14	Based on interview, record review, and observation the licensee did not ensure the bathrooms were in good repair which poses an immediate health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
Type A 08/15/2024 Section Cited CCR 87303(e)(2)	1 2 3 4 5 6 7	(e) Water supplies and plumbing fixtures shall be maintained as follows (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a statement of understanding of the section cited to LPA Dolores via email by POC due date.
	8 9 10 11 12 13 14	Based on interview, record review and observation the licensee did not ensure the hot water temperature was not more than 120 degrees F measuring between 125 – 130 degrees F which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 13

Control Number 26-AS-20230713135124

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: WILLOW GLEN SENIOR LIVING	FACILITY NUMBER: 435202725
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/21/2024 Section Cited CCR 87507(f)	1 2 3 4 5 6 7	(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a statement of understanding of the section cited above to LPA Dolores via email by POC due date.
	8 9 10 11 12 13 14	Based on interview, record review, and observation the licensee did not ensure to comply with all the applicable terms and conditions set forth in the admission agreement as R1’s private caregiver was providing R1 with basic services which poses an potential health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
	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.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 13

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
07/13/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230713135124

FACILITY NAME:	WILLOW GLEN SENIOR LIVING		FACILITY NUMBER:	435202725
ADMINISTRATOR:	PAMELA D. PERALTA		FACILITY TYPE:	740
ADDRESS:	2991 FAIRCLIFF CT		TELEPHONE:	(408) 914-1147
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	6	CENSUS: 5	DATE:	08/14/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Irish Ladwig		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Facility staff inappropriately touched resident
Facility is not securely storing medication
Facility is not following facility meal plan

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

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

LIC9099 (FAS) - (06/04)

Page: 3 of 13

Control Number 26-AS-20230713135124

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: WILLOW GLEN SENIOR LIVING	FACILITY NUMBER: 435202725
	VISIT DATE: 08/14/2024

NARRATIVE

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Facility staff inappropriately touched resident
It was alleged that a male staff had inappropriately touched R1. It was alleged that an alarm went off in R1’s room and the staff (S2) saw R1 was almost falling out be bed. S2 caught R1 and R1 perceived it to be inappropriate touching. It was alleged that S2 touched R1 around the abdomen area.

Throughout the course of this investigation, 6 residents, 4 staff, and 1 witness was interviewed.

Based on staff interview, S2 denied any incidents of inappropriately touching of residents. S2 stated there was an incident that happened at the dining table where R1 looked like he/she was about to fall. S2 ran and grabbed R1 under his/her arm because R1 almost fell down. S2 did not remember where he/she touched R1. S2 states it happened once and it was only to help R1 because he/she was about to fall. 3 out of 3 staff denied the observation of staff touching residents and R1 inappropriately.

Based on resident interview, 5 out of 6 resident’s denied staff inappropriately touching them. 5 out of 6 residents’ denied the observation of staff inappropriately touching another residents. 1 out of 6 resident’s was unable to be interviewed.

Based on interview with R1's private caregiver (W1), W1 only heard of the incident. It was stated that R1 did not have a private caregiver at the time.

Facility is not securely storing medication
It was alleged that R1’s private caregiver kept one of R1's medication in R1’s room.

Based on interview with R1’s private caregiver (W1), it was stated the facility’s caregivers dispenses R1’s medication and W1 gives the medication in a cup to R1. W1 states the medication is locked in the kitchen, which W1 does not have access to the medication cabinet.

PAGE 2 OF 4.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 13

Control Number 26-AS-20230713135124

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: WILLOW GLEN SENIOR LIVING	FACILITY NUMBER: 435202725
	VISIT DATE: 08/14/2024

NARRATIVE

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On 07/19/2023, LPA Dolores entered into R1’s room and did not observe medication that was left out in R1's room. LPA Dolores toured the facility and entered in all resident bedrooms and did not observe any medication that was accessible to the residents. LPA observed the medication storage area was secured in a locked cabinet and inaccessible to residents in care.

On 01/24/2024, LPA Monter observed the medication storage area was secure and inaccessible to residents in care.

Facility is not following facility meal plan
It was alleged that the facility is not following the meal plan because there was a time where there were no fresh fruits or vegetables delivered and the resident’s were eating canned food and microwave foods. It was also alleged that the resident’s were not being served green salads.

Throughout the course of this investigation, 6 residents and 3 staff were interviewed.

Based on resident interview, 5 out of 6 residents states they get vegetables and fruits every day. 1 out of 6 residents was unable to be interviewed.

R2 states they eat a lot of frozen food like vegetables and meat. It was stated they have Salisbury steak with fresh mashed potatoes and vegetables. It was stated that the facility serves them salad. It was stated that they have fruit every day. R3 states they get fresh vegetables practically every day to include a salad. R3 states he/she doesn’t always eat the salad. R4 states the vegetables are mushy and frozen. R4 states they get frozen vegetables 5 days a week. R4 states that sometimes they get fresh beats and carrots. R4 preferred certain fruits than what the facility was serving. R5 states the food is very good. R4 states they serve both frozen and fresh fruits and vegetables. R6 states the facility serves ordinary things to include fruits and vegetables.

PAGE 3 OF 4.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 13

Control Number 26-AS-20230713135124

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: WILLOW GLEN SENIOR LIVING	FACILITY NUMBER: 435202725
	VISIT DATE: 08/14/2024

NARRATIVE

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Based on staff interview, S1 states to ask the resident’s what they want to eat. It was stated that they serve salad every afternoon. S1 states they do not serve frozen vegetables and it’s always fresh. S2 states they ask the residents what they want to eat because each resident likes different dishes. S2 states they use both frozen and fresh vegetables but usually use fresh vegetables.

The Administrator states that groceries are delivered every 2 weeks and as needed. It was stated that the resident’s are very specific with what they want to eat and ADM accommodates to their needs if able. ADM states the menu posted on the refrigerator is only a sample.

On 07/19/2023, LPA Dolores observed the kitchen had at least 2 days worth of perishables and 7 days worth of non-perishable foods. LPA Dolores observed fruits to include apples and watermelon and vegetables to include lettuce, tomatoes, onions, and potatoes.

The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the allegations did/did not occur. No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Licensee Irish Ladwig and a copy of the report was provided.

PAGE 4 OF 4.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 13