435202738-12-27-2024-26-AS-KHOS-DCKMJG-20250103083904

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202738
Report Date: 12/27/2024
Date Signed: 12/27/2024 11:24:08 AM

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
04/24/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230424100617

FACILITY NAME:	GARDENS SENIOR LIVING		FACILITY NUMBER:	435202738
ADMINISTRATOR:	ARELLANO, ROSARIO		FACILITY TYPE:	740
ADDRESS:	6162 VALLEY GLEN DRIVE		TELEPHONE:	(408) 807-5846
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 4	DATE:	12/27/2024
		UNANNOUNCED	TIME BEGAN:	10:00 PM
MET WITH:	Staff - Rex Deocales		TIME COMPLETED:	11:30 PM

ALLEGATION(S):

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- Staff did not observe resident sustained an infection
- Staff did not communicate with resident’s responsible party in a change of condition
- Staff did not provide resident with adequate dental hygiene
- Staff did not ensure resident was hydrated
- Staff did not assist resident with incontinence needs during the night
- Staff did not dispense vitamins to resident in care

INVESTIGATION FINDINGS:

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On 12/27/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver findings regarding the allegation received. LPA met with staff Rex Deocales and explained the purpose of today's visit. During today's visit LPA Vado spoke to co-licensee Chrstine Aurellano and discssed the findings and the allegations.

During the investigation interviews were conducted, documents are reviewed, and facility observations were made. Per 5/5 staff, they were not aware of any pain or signs of an infection to report. It is common practice to contact repsponsible party if there was anything observed that is out of the ordinary. There are lso case notes provided to the Department to show observations made as the resident is incontinent and was montiored closely due to this.

Conitinued on next page...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024

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-20230424100617

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: GARDENS SENIOR LIVING	FACILITY NUMBER: 435202738
	VISIT DATE: 12/27/2024

NARRATIVE

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Page 2 - LIC9099

Per these interviews, staff did provide dental hygiene regularly and provided documentation to show a recent dental visit at the time of the complaint. Staff also confirm that they met incontinence needs during the night and took steps to change and help prevent any rashes or infection. Staff provide medications and vitamins as prescribed but cannot force a resident if they refuse. This is marked in the records if refused. The facility did not maintain a regular hydration log at the time, but staff interviews stated that they did encourage regular hydration to the resident and water cups were provided to resident. There was a cup present in the room that is a designated size and the daily goal is to have residents consume a certain number of ounces to ensure hydration. Cups were observed in other resident rooms as well. 3/3 residents interviewed showed that the facility provided the services needed as indicated in the allegations received, and did not have any complaints or issues regarding each allegation pertaining to their care. Based on interviews conducted, and documentation reviewed that was received, these allegations are unsubstantiated. It cannot be determined that all these allegations took place described.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Report is reviewed with staff person Rex Deocales and a copy of this report is provided on this day.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024

LIC9099 (FAS) - (06/04)

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