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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202759
Report Date: 09/17/2024
Date Signed: 09/17/2024 05:23:59 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
11/29/2022 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20221129092607
FACILITY NAME:WESTGATE VILLAFACILITY NUMBER:
435202759
ADMINISTRATOR:TAYAG, AIDAHFACILITY TYPE:
740
ADDRESS:5425 MAYME AVENUETELEPHONE:
(408) 366-6510
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:60CENSUS: 56DATE:
09/17/2024
UNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Aidah TayagTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff are not meeting residents' housekeeping needs.
Facility staff are not meeting residents' basic care needs (showering, laundering, checks on residents).
Facility staff are not following resident's doctors notes.
Facility staff does not provide residents a daily menu.
Facility staff mixed sick residents with uninfected residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Executive Director (ED) Aidah Tayag.

On 11/29/2022, the Department received a complaint with the above allegations.

On 12/06/2022, the Department conducted an initial investigation visit. LPA interviewed ED, 3 staff, and 3 residents. LPA requested resident roster, staff roster, staff schedule, weekly menu, resident physician report, Appraisal/Needs and Services Plan, Medication Administration Records, and showering schedule.

On 4/19/2024, the Department conducted an investigation visit. LPA interviewed 7 staff and 6 residents.

Continue on LIC9099-C. Page 1 of 6.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
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 12
Control Number 26-AS-20221129092607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: WESTGATE VILLA
FACILITY NUMBER: 435202759
VISIT DATE: 09/17/2024
NARRATIVE
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Facility staff are not meeting residents' housekeeping needs:
On 12/06/2022, LPA interviewed Executive Director (ED) Aidah Tayag. ED stated the housekeepers conduct deep cleaning one time per week and as needed for resident rooms.

LPA interviewed 2 residents and toured the rooms. 2 out of 2 residents stated the facility staff clean the resident room at least one time per week. 1 out of 2 residents stated the facility has good cleaning staff and he/she has no concern about the house keeping service. LPA did not see the resident rooms were not in sanitary condition.

LPA toured and interviewed resident R1. LPA did not see R1's room was not in sanitary condition. LPA interviewed R1. R1 has a disorder that affects the communication and speech capabilities. R1 was unable to answer the questions exactly but just talking about his/her personal property issue. R1 was unable to describe what housekeeping needs were not met.

On 4/19/2024, LPA interviewed 2 staff. 2 out of 2 staff stated the facility housekeepers clean resident rooms one time per week and as needed.

LPA interviewed Housekeeper Supervisor (HS). HS stated the facility housekeepers clean the cognitive impairment resident rooms every Monday through Friday and 1- 2 times per week for remaining resident rooms. HS stated the housekeeper conducted the clean including changing residents' sheets.

LPA interviewed 6 residents and toured the rooms. 6 out 6 residents stated housekeepers clean their rooms at least one time per week and as needed. LPA did not see any resident room was not in sanitary condition.

Based on the observation and interviews, no evidence to indicate the facility staff are not meeting residents' housekeeping needs.


Continue on LIC9099-C. Page 2 of 6.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 12
Control Number 26-AS-20221129092607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: WESTGATE VILLA
FACILITY NUMBER: 435202759
VISIT DATE: 09/17/2024
NARRATIVE
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Facility staff are not meeting residents' basic care needs (showering, laundering, checks on residents):

On 12/6/2022, LPA interviewed ED. ED stated residents have two scheduled showers per week and as needed, and caregivers conduct the laundries for residents after residents' showers. ED stated staff check residents every two hours. ED stated staff check residents with special health condition more often than every two hours.

LPA interviewed 2 residents. 2 out of 2 residents stated they have 2 showers per week and staff check them every two hours or even less than two hours.

On 4/19/2024, LPA interviewed 4 staff. 4 out of 4 staff stated residents have at least 2 showers per week. 4 out of 4 staff stated each resident has a scheduled laundry per week. 4 out of 4 staff stated staff check residents every two hours. 1 out of 4 staff stated before the facility had resident laundries after residents' showers, and now the facility improves to that each resident to have a scheduled laundry per week and as needed.

LPA interviewed 6 residents. 5 out of 6 residents stated they have two showers per week, and 1 out 6 resident stated he/she has 3 showers per week. 5 out of 6 residents stated they have one laundry every week. 1 out 6 residents stated he/she has 3 laundries per week. 6 out of 6 residents stated the facility staff check them every two hours.

Based on the interviews with staff and residents, there is no evidence to indicate residents' basic care needs were not met.


Continue on LIC9099-C. Page 3 of 6.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 10 of 12
Control Number 26-AS-20221129092607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: WESTGATE VILLA
FACILITY NUMBER: 435202759
VISIT DATE: 09/17/2024
NARRATIVE
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Facility staff are not following resident's doctors notes:
The facility staff are alleged that the facility did not administer nutritional supplement to resident.

On 12/06/2022, LPA interviewed ED. ED stated the facility staff administer medications to residents based on doctor's order/prescription in writing. ED stated PRN medications or nutritional supplements also need doctor's order/prescription in writing for the facility staff to administer to residents.

On 4/19/2024, LPA interviewed staff Community Nursing Director (CNR). CNR stated the facility staff administer medications, PRN medications, nutrition supplements to residents based on doctor prescriptions in writing. CNR stated he/she was not aware of resident R1 had doctor prescription of nutrition supplements.

Based on the review of R1's physician report, medication list and medical documents, no doctor's order/prescription of nutritional supplement was found for R1.

Based on the interviews and records reviewed, no evidence to indicate that the facility staff are not following resident's doctor notes.

Facility staff does not provide residents a daily menu:
On 12/06/2022, LPA interviewed ED. ED stated the facility always has weekly menu available and posted. ED stated there are daily menu on the dining tables and available in front of the entrance of the dining room. ED stated the dietary supervisor talked to resident R1 for the food he/she wants before meal time.

LPA interviewed 2 staff. 2 out of 2 staff stated the weekly menu are always posted. LPA interviewed 2 residents. 2 out of 2 residents stated the facility posts the weekly menu.

On 4/19/2024, LPA interviewed 2 facility manager/directors. Both stated the facility always has weekly menu posted. Both stated there are daily menu available on the dining table and available in the front of the dining room. Both stated facility staff provides daily menu to resident R1 or talk to R1 for the meal food before the meal time.

Continue on LIC9099-C. Page 4 of 6.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 12
Control Number 26-AS-20221129092607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: WESTGATE VILLA
FACILITY NUMBER: 435202759
VISIT DATE: 09/17/2024
NARRATIVE
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LPA interviewed 3 staff. 3 out of 3 staff stated the facility has weekly menu. 1 out 3 staff stated he/she takes the daily menu to residents every day. 1 out 3 staff stated he/she takes the week menu to residents and there are daily menu available in the dining room. 1 out 3 staff stated the kitchen staff always give weekly menu to residents.

LPA interviewed 6 residents. 6 out of 6 residents stated the facility has weekly menu. 2 out 6 residents stated the facility has daily menu in the dining room. 1 out of 6 resident stated he/she does not care about the menu because the facility food is good.

Marketing director showed LPA the daily menu during LPA's visit the facility. LPA observed the facility weekly menu were posted, and the daily menu was placed at the dining table and in front of the dining room

By Title 22, weekly menu is required to posted or provided. Daily menu is not mandatory to provide directly to residents.

Based on the interviews, observation, and document reviewed, there is no evidence to indicate the staff does not provide daily menu.

Facility staff mixed sick residents with uninfected residents:

On 12/6/2022, LPA interviewed ED. ED stated on the beginning of November, the facility had gastrointestinal cases. ED stated the facility took actions on that and reported to local health department and CCL office. ED stated the facility closed the dining room, and stopped the facility activities, and had resident to stay at their rooms. ED stated the facility isolated the infected residents in their rooms.

LPA interviewed a resident who stated at the beginning of November 2022, he/she got diarrhea, the facility activity was stopped, the dining room was closed, and he/she was isolated at the bedroom.

Page 5 of 6.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 11 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
11/29/2022 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20221129092607

FACILITY NAME:WESTGATE VILLAFACILITY NUMBER:
435202759
ADMINISTRATOR:TAYAG, AIDAHFACILITY TYPE:
740
ADDRESS:5425 MAYME AVENUETELEPHONE:
(408) 366-6510
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:60CENSUS: 56DATE:
09/17/2024
UNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Aidah TayagTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not meeting resident's nutritional health needs/religious food beliefs.
Facility staff served residents raw meat.
Facility staff engaged in a verbal altercation with resident.
Facility staff threatened resident.
Facility staff does not ensure that residents' items don't go missing (clothes, personal items).
Facility staff are insufficient to meet the needs of the residents.
INVESTIGATION FINDINGS:
1
2
3
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5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Executive Director (ED) Aidah Tayag.

On 11/29/2022, the Department received a complaint with the above allegations.

On 12/06/2022, the Department conducted an initial investigation visit. LPA interviewed ED, 3 staff and 3 residents. LPA requested resident roster, staff roster, staff schedule, weekly menu, resident physician report, Appraisal/Needs and Services Plan, Medication Administration Records, and showering schedule.

On 4/19/2024, the Department conducted an investigation visit. LPA interviewed 7 staff and 6 residents.

Continue on LIC9099-C. Page 1 of 6.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 12
Control Number 26-AS-20221129092607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: WESTGATE VILLA
FACILITY NUMBER: 435202759
VISIT DATE: 09/17/2024
NARRATIVE
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Facility staff are not meeting resident's nutritional health needs/religious food beliefs:
Resident R1 cannot eat pork due to religious reasons. The facility was alleged that the facility staff are not meeting R1's nutritional health needs.

On 12/06/2022, LPA interviewed ED. ED stated R1's family member already communicated with him/her regarding that R1 cannot eat pork due to religious reason before R1 moved in the facility. ED stated he/she already notified dietary supervisor regarding R1's special needs for the meals before R1 moved in the facility.

ED stated the facility provides meal menu with the options/alternatives to choose if residents do not like the meals provided. ED stated the facility has daily menu on the dining room table and daily menu by the entrance of the dining room. ED stated R1 is particular at meal food. ED stated the dietary supervisor always contacted R1 to make sure what kind of food he/she likes for the meal before the meal time. ED stated the facility provides chicken, beef, turkey, shrimp and seafood for R1's protein needs.

LPA interviewed dietary supervisor (S1). S1 stated he/she knows R1 cannot eat pork. S1 stated the facility provides different options/alternatives for residents to choose. S1 stated he/she or other staff talks to R1 before the meal time to make sure what kind of food he/she likes.

LPA interviewed 2 staff. 2 out of 2 staff stated they know R1 does not eat pork. Both stated the facility did not provide pork to R1. Both stated R1 is particular on the meal food.

On 4/19/2024, LPA interviewed Community Nursing Director (CNR). CNR stated R1 does not eat pork, but R1 eat kitchen, beef, turkey, shrimp and seafood. CNR stated the facility staff talk to R1 before the meal time to know what kind of food he/she likes. CNR stated R1 is particular at meal food.

LPA interviewed 4 staff. 4 out 4 staff stated the facility provides weekly menu, and there are daily menus on the dining table and in front of the dining room entrance. 4 out of 4 stated kitchen staff or caregivers talk to R1 before the meal time to make sure what kind of food he/she likes.

Based on the interviews and document reviewed, there is no evidence to indicate that the facility staff are not meeting resident's nutritional health needs. Continue on LIC9099-C. Page 2 of 6.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 12
Control Number 26-AS-20221129092607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: WESTGATE VILLA
FACILITY NUMBER: 435202759
VISIT DATE: 09/17/2024
NARRATIVE
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Facility staff served residents raw meat:
On 12/06/22, LPA interviewed ED. ED stated the facility staff always check the food before delivered to residents. ED stated if staff found meal with raw meat, they won't deliver to residents.

LPA interviewed 2 residents. 2 out of 2 residents stated they never received meal with raw meat.

On 4/19/2024, LPA interviewed Community Nursing Director (CNR). CNR stated the facility staff always check the food before delivering to residents. CNR stated if staff find meal with raw meat, they will return to kitchen.

LPA interviewed 6 residents. 6 out of 6 residents stated they never received meal with raw meat.

Based on the interviews, there is no evidence to indicate the facility staff served residents with raw meat.

Facility staff engaged in a verbal altercation with resident:
On 12/06/2022, LPA interviewed Executive Director (ED) Aidah Tayag. ED stated on 11/20/2022 he/she received a report regarding an incident happened in the kitchen between staff S1 and resident R1. Resident R1 was upset about the food. ED stated on 11/21/2022, he/she interviewed S1. S1 denied that he/she engaged in an alteration with R1. ED stated he/she interviewed R1 but R1 refused to talk about the incident.
LPA interviewed staff S1. S1 stated resident R1 came to kitchen to question him/her and yelled at him/her. S1 stated he/she explained to R1 carefully and clearly. S1 stated he/she did not yell at R1 or threaten R1.
LPA interviewed 2 staff (S2, S3). Both stated resident R1 is particular at food. Both stated they heard there was an incident that R1 and S1 had alteration in the kitchen, but they did not observe what happened.

On 4/19/2024, LPA interviewed a staff S4. S4 stated he/she saw resident R1 went to kitchen to argue with staff S1 in November 2022, but he/she was unable to hear what they were talking about. S4 stated he/she was washing dishes and was unable to hear if any yelling between R1 and S1.


Continue on LIC9099-C. Page 3 of 6.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 12
Control Number 26-AS-20221129092607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: WESTGATE VILLA
FACILITY NUMBER: 435202759
VISIT DATE: 09/17/2024
NARRATIVE
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Facility staff threatened resident:
On 12/06/2022, LPA interviewed ED. ED stated on 11/20/2022 he/she received a report regarding an incident happened in the kitchen between staff S1 and resident R1. Resident R1 was upset about the food. ADM stated he/she did not receive any report that facility staff threatened residents.

LPA interviewed 2 staff. 2 out of 2 staff stated they heard an incident that a staff and a resident had an alteration but they did not see the incident in person. Both stated they did not see or hear staff threatening resident.

LPA interviewed staff S1. S1 stated resident R1 came to kitchen to complain about the food. S1 stated R1 is hard to communicate. S1 denied he/she threatened R1.

LPA interviewed resident R1. R1 is hard to communicate with. R1 was unable to answer the questions. LPA interviewed 2 residents. 2 out of 2 residents stated they were not aware of any incident that staff threatened resident.

On 12/07/2022, ED contacted LPA via email regarding the incident S1 threatened resident R1. ED stated that on 11/18/2022, R1 went to kitchen to argue with staff S1 regrading the food provided by the facility. R1 was angry and yelled at S1. S1 tried to clam down R1 but unsuccessful. ED stated R1 had an alteration with S1. But S1 did not threatened R1. ED stated he/she tried to talk with R1 regarding the incident, but R1 refused to talk about it. ED interviewed 2 staff on site in the kitchen when the incident occurred. Both stated they did not see or hear S1 threatened R1. ED stated S1 denied he/she threatened R1.

On 4/19/2024, LPA interviewed a kitchen staff who was on site when the incident occurred on 11/18/2022 that R1 had an altercation with S1 in the kitchen. The kitchen staff stated he/she did not see/hear S1 threatened R1.

LPA interviewed 6 residents, 6 out of 6 residents stated they were not aware of any incidents that staff threatened residents.

Based on the interviews, no evidence to indicate that the facility staff threatened residents.
Continue on LIC9099-C. Page 4 of 6.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 12
Control Number 26-AS-20221129092607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: WESTGATE VILLA
FACILITY NUMBER: 435202759
VISIT DATE: 09/17/2024
NARRATIVE
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Facility staff does not ensure that residents' items don't go missing (clothes, personal items):

On 12/06/2022, LPA interviewed ED. ED stated he/she received some reports that residents were missing clothes after laundry. ED stated the lost clothes were not in residents' valuable property list. ED stated staff were helping to find residents' clothes in the laundry room after residents reported missing clothes.

LPA interviewed 3 residents. 2 out of 3 residents stated they lost clothes after laundry.

On 4/19/2024, LPA interviewed 7 staff. 4 out of 7 staff stated they heard residents complaining about losing clothes after laundry. LPA interviewed 6 residents. 2 out of 6 residents stated they missed clothes after laundry. 1 out of 6 residents stated he/she was able to find his/her clothes in the laundry room if he/she found missing clothes after laundry. 3 out 6 residents stated they did not lose clothes after laundry.

LPA interviewed CNR. CNR stated the facility makes improvement from conducting laundry after residents' showers to have scheduled laundry for residents to prevent residents missing clothes after laundry. CNR stated this prevents the resident losing clothes after laundry. CNR stated it is easier to locate the owner of the missing clothes in the laundry room if clothes were found in the laundry room after the laundry.

Based on the interviews, the facility made some actions to ensure resident not to lose clothes after laundry.

Continue on LIC9099-C. Page 5 of 6.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 12
Control Number 26-AS-20221129092607
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: WESTGATE VILLA
FACILITY NUMBER: 435202759
VISIT DATE: 09/17/2024
NARRATIVE
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Facility staff are insufficient to meet the needs of the residents:

On 12/06/2022, LPA interviewed ED. ED stated the facility had 45 residents and the facility had 4 caregivers at the first and the second shifts, and 3 caregivers at the third shift.

LPA interviewed a staff who stated the facility has 4 caregivers and 1 Med Tech at the first shift, 4 caregivers and 1 Med Tech at the second shift, and 1 Med Tech/caregiver and 2 caregivers at the third shift.

LPA interviewed 2 residents. 1 out 2 residents stated the facility does not have insufficient staffing issue. 1 out of 2 resident stated the facility could hire more staff.

on 04/19/2024, LPA interviewed 6 residents. 5 out 6 residents stated the facility does not have insufficient staffing issue. 1 out 6 resident stated the facility could hire more staff.

Based on the interviews, there is no evidence to indicate the facility staff are insufficient to meet the needs of the residents.

Based on investigation, observations, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No citations noted at today’s complaint investigation visit. Exit interview was conducted with ED. This report was provided to ED for signature. A copy of the report was provided to ED.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 12
Control Number 26-AS-20221129092607
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: WESTGATE VILLA
FACILITY NUMBER: 435202759
VISIT DATE: 09/17/2024
NARRATIVE
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On 4/19/2024, LPA interviewed Community Nursing Director (CNR). CNR stated around October 2022 or November 2022, the facility had 5 residents had gastrointestinal infections. The facility closed the dining room and stopped the facility activity. CNR stated the facility isolated the infected residents in their rooms.

LPA reviewed the email log that the facility communicated with the local health department. The facility followed the instructions provided by the local health department.

Based on the interviews and record reviewed, the facility stopped the facility activity, closed the dining room, and isolated infected residents in their rooms. The facility notified the local health department and followed the local health department's instructions.

There is no evidence to indicate the facility staff mixed sick residents with uninfected residents.

The Department has investigated the above allegation. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegations is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citation noted today. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED.

Page 6.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 12 of 12