435202759-9-17-2021-26-AS-RMAO-C79SK4-20210927135607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202759
Report Date: 09/17/2021
Date Signed: 09/17/2021 01:38:55 PM

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
09/22/2020 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20200922121209

FACILITY NAME:	WESTGATE VILLA		FACILITY NUMBER:	435202759
ADMINISTRATOR:	TAYAG, AIDAH		FACILITY TYPE:	740
ADDRESS:	5425 MAYME AVENUE		TELEPHONE:	(408) 366-6510
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY:	60	CENSUS: 44	DATE:	09/17/2021
		UNANNOUNCED	TIME BEGAN:	10:23 AM
MET WITH:	Aidah Tayag, ADM		TIME COMPLETED:	11:32 AM

ALLEGATION(S):

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Staff physically abused resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted a complaint investigation visit today to deliver investigation finding.

On 09/22/2020, the Department received the above complaint allegation.

On 09/23/2020, a tele-visit inspection was conducted. Resident's roster, staff roster, staff work schedule, R1's Appraisal/Needs and Services Plan, R1's Functional Capability Assessment , and R1's Physician Report were obtained.

Continued, see LIC 9099-C, page 2 of 3.

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: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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 3

Control Number 26-AS-20200922121209

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: WESTGATE VILLA	FACILITY NUMBER: 435202759
	VISIT DATE: 09/17/2021

NARRATIVE

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Staff physically abused resident:
Between 10/05/2020 and 10/08/2020, the Department interviewed residents R1 and R2. R1 was not able to provide information of how R1 sustained injury due to poor memory while R2 (R1’s roommate) stated the facility staff did not hurt R1. R2 stated R2 heard R1 fell down.

Based on review of R1’s facility file and the facility emails to R1’s family member showed that facility staff notified R1’s family member regarding R1’s skin discoloration on R1's body and changes on medical condition. R1’s doctor has been informed of R1’s medical condition.

On 8/26/2020, R1 was examined by R1’s doctor who started a supplementation and the resumption of Calcium given for R1’s history of fragility fractures.

On 09/06/2020, the facility reported to R1’s doctor that R1 had a purplish discoloration on R1’s left knee and lateral thigh with no swelling or pain.

Based on R1’s medical review, R1 has left side deficits, and is wheelchair dependent. R1 has episodes of confusion, combative behavior and refusal of care when upset. There was no evidence of abuse from R1’s medical exam.

On 09/16/2020, the department interviewed Staff (S1) who stated that R1 was experiencing pain and reported to facility nurse. Facility nurse assessed R1 who was not able to verbalize the location of R1’s pain. On the same day at approximately 11:00 hours R1 complained of knee pain. R1 was assessed wherein R1’s knee was swollen and warm but not discolored. Facility informed R1 doctor and scheduled a video Tele Visit. R1 was prescribed pain reliever and topical cream and icing. R1 was monitored by staff but did not show any improvement. R1 was transported to the hospital on 09/17/2020.

On 9/18/2020, facility filed an Unusual Incident Report to Department regarding R1's swelling of the knee. None of the facility staff interviewed during the investigation could explain the cause of R1’s injuries.

Continued, see LIC 9099-C, page 3 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20200922121209

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: WESTGATE VILLA	FACILITY NUMBER: 435202759
	VISIT DATE: 09/17/2021

NARRATIVE

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On 10/01/2020, the department interviewed a staff (S1). S1 stated S1 could not tell how R1’s injury occurred or how long R1’s leg had been injured. The department interviewed 8 caregivers (S1 - S8), and all of them denied abusing R1 or having knowledge of other staff abusing R1

On 10/12/2020, the Department interviewed R1’s Orthopedic doctor (OD) about R1’s fracture. OD stated that R1 has a low bone density which makes it easier for a person to fracture a bone easier than who has a normal energy.

The Department has investigated the above allegation. Based on interviews conducted and records reviewed, 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 deficiencies or citations issued at today’s complaint investigation visit.

Exit interview conducted with Administrator (ADM). A copy of this report was provided for signature. A copy of this report was emailed to ADM.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC9099 (FAS) - (06/04)

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