435202754-8-22-2023-26-AS-RMAO-CV8KC7-20230831074639

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202754
Report Date: 08/22/2023
Date Signed: 08/22/2023 05:10:10 PM

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
01/12/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230112102321

FACILITY NAME:	PRIMAVERA GARDENS		FACILITY NUMBER:	435202754
ADMINISTRATOR:	MICHAEL ELSOUSOU		FACILITY TYPE:	740
ADDRESS:	16095 CHURCH STREET		TELEPHONE:	(408) 778-5683
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	20	CENSUS: 16	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Administrative Assistant Nick Elsousou		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Licensee does not ensure toilets and bathing facilities are kept clean and in operating condition
Licensee does not prevent the presence of pests in the facility
Licensee does not ensure kitchen areas are kept clean
Licensee did not ensure solid waste is properly disposed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrative assistant (AA) Nick Elsousou.

Licensee does not ensure toilets and bathing facilities are kept clean and in operating condition/ License does not ensure kitchen areas are kept clean/ Licensee did not ensure solid waste is properly disposed.

On 01/18/2023, LPA Dolores toured the facility, including resident bedrooms during a complaint investigation. LPA did observed facility bathrooms and kitchen in good condition. LPA did not observe facility in disrepair.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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-20230112102321

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: PRIMAVERA GARDENS	FACILITY NUMBER: 435202754
	VISIT DATE: 08/22/2023

NARRATIVE

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On 08/22/2023 LPA Monter toured the facility including resident bedrooms. LPA observed all facility bathrooms in good condition. LPA observed facility kitchen in good condition. LPA did not observe the facility in disrepair.

LPA Monter interviewed 9 residents and 4 staff regarding the allegations. 6 out of 9 residents were happy with the facility's cleanliness and had no complaints. 1 spouse of a non verbal resident did not have complaints regarding the facility's cleanliness. 3 out of the 9 residents are not verbal and could not answer LPA's questions. 4 out of 4 staff stated the facility maintains the bathrooms clean based on shift; AM, PM, & NOC. Staff also stated they have a bathroom cleaning schedule.

Based on the interviews conducted with clients & staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Licensee does not prevent the presence of pests in the facility

On 01/18/2023, LPA Dolores toured the facility, including resident bedrooms and kitchen during a complaint investigation. LPA did observe pests in the facility. ADM provided LPA with pest control invoices.

On 08/22/2023 LPA Monter toured the facility including resident bedrooms and kitchen. LPA did not observe pests during the tour of the facility. LPA Monter interviewed 9 residents and 4 staff regarding the allegations. 5 out of 9 residents stated the facility had no pests such as cockroaches and had no complaints. 1 spouse of a non verbal resident stated he/she has not seen pests such as cockroaches. 3 out of the 9 residents are not verbal and could not answer LPA's questions. 1 out of 9 residents could not remember and answer LPA's questions. 4 out of 4 staff stated the facility does not have a pests such as cockroaches.

Based on the interviews conducted with clients & staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
01/12/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230112102321

FACILITY NAME:	PRIMAVERA GARDENS		FACILITY NUMBER:	435202754
ADMINISTRATOR:	MICHAEL ELSOUSOU		FACILITY TYPE:	740
ADDRESS:	16095 CHURCH STREET		TELEPHONE:	(408) 778-5683
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	20	CENSUS: 16	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Administrative Assistant Nick Elsousou		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility does not have sufficient staff to meet the needs of residents
Licensee does not ensure that medication records are accurate

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrative assistant (AA) Nick Elsousou.

The department received a complaint on 01/12/2023 alleging the facility does not have sufficient staff to meet the needs of the residents.

On 01/18/2023, LPA Dolores toured the facility, including resident bedrooms, bathrooms, kitchen, laundry room, shower rooms, hallways, dining room, and exterior. LPA did not observe residents in disheveled state/ unattended. LPA observed residents rooms well maintained.

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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 5

Control Number 26-AS-20230112102321

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: PRIMAVERA GARDENS	FACILITY NUMBER: 435202754
	VISIT DATE: 08/22/2023

NARRATIVE

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On 08/22/2023 LPA Monter toured the facility including resident bedrooms, bathrooms, dinning area and kitchen. LPA did not observe residents disheveled or unattended. Residents rooms were well maintained. LPA did not observe the facility in disrepair.

LPA Monter interviewed 9 residents and 4 staff regarding the allegations. 6 out of 9 residents stated the facility has enough staff to attend to their needs and had no complaints. 1 spouse of a non verbal resident stated he/she is happy with the care being provided. 3 out of the 9 residents interviewed are not verbal and could not answer LPA's questions. 4 out of 4 staff stated the facility has sufficient staff to meet the residents needs.

The Department has completed the investigation of the above allegations. Based on observation & interviews conducted, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Licensee does not ensure that medication records are accurate

On 01/18/2023, LPA Dolores observed residents Medication Administrator Record (MAR). LPA observed the PM medications were already signed off by staff. Staff S1 stated if a resident refuses medication, then the staff are supposed to circle their pre-signed initial and write what happened in the nurses note located on the back of the MAR. S1 states the facility does not have any issues with residents refusing their medication.

LPA Monter interviewed S1. S1 stated the procedure is the medtech on duty will pre-pour the meds for that day and signs off on the mars once they are given. If the residents refuse then he/she will take it back to med room and re-try again. S1 stated the facility's residents don't refuse their medication. S1 stated if they still refuse he/she will document it on the nurses note section.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20230112102321

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: PRIMAVERA GARDENS	FACILITY NUMBER: 435202754
	VISIT DATE: 08/22/2023

NARRATIVE

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On 08/22/2023, LPA Monter reviewed medication records for 3 residents. LPA did not observe any discrepancies when cross referencing the medications and the log for the 3 residents reviewed.

The Department has completed the investigation of the above allegations. Based on observation & interviews conducted, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited at this time.
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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5