435202754-8-23-2023-26-AS-RMAO-CVUSHS-20230920135402

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202754
Report Date: 08/22/2023
Date Signed: 08/23/2023 09:09:56 AM

Unsubstantiated

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
11/19/2020 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20201119112952

FACILITY NAME:	VILLA SERENA OF MORGAN HILL		FACILITY NUMBER:	435202754
ADMINISTRATOR:	ELSOUSOU, NICOLAS		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:	NICK ELSOUSOU		TIME COMPLETED:	04:26 PM

ALLEGATION(S):

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Staff handled resident(s) in rough manner.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Steve Chang and Manuel Monter conducted an unannounced investigation visit, and met with Administrator Assistant (AA) MICK ELSOUSOU.

On 11/19/2020, the Department received a complaint with the allegation that Staff handled resident(s) in rough manner.

On 11/23/2020, the Department conducted an initial complaint visit, Staff and Resident roster and Resident Physician’s Report, Appraisal/Needs and Services Plan, and Functional Capability Assessment were obtained.

Continue on LIC9099-C. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
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 2

Control Number 26-AS-20201119112952

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: VILLA SERENA OF MORGAN HILL	FACILITY NUMBER: 435202754
	VISIT DATE: 08/22/2023

NARRATIVE

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Staff handled resident(s) in rough manner:

On 8/22/2023, LPAs interviewed Administrator Assistant (AA) NICK ELSOUSOU. Current roster of residents and LIC500 were obtained. AA stated the last working date of staff S1 was 10/07/2022. LPAs interviewed staff S2. S2 stated he/she worked with S1. AA and S2 stated they did not witness or hear any incidents that S1 treated residents in rough manner. LPAs interviewed staff S3 and S4. Both of them did not know S1, and they did not hear any incidents that staff treat residents in rough manner.

LPAs interviewed S1 over the phone. S1 denied the allegation, and claimed he/she is a good caregiver.

LPAs interviewed 15 residents. 8 out 15 residents were unable to communicate and answer LPA's questions. 2 out of 15 residents(R1, R2) were living in the facility prior to the complaint being filed. R1 is unable to communicate. R2 stated he/she did not witness or hear any incident that S1 treat resident in rough manner. 8 out of 15 residents moved in the facility after October 2022, and they did not know S1, and did not hear any compliant regarding staff treat resident in rough manner. All residents interviewed denied being treated in a rough manner by staff.

The Department has investigated the above allegation. Based on interviews conducted with staff and residents, the department has found the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to show the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with AA. A copy of the report was provided to AA.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
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 2