435202759-2-1-2022-26-AS-RMAO-CC4TFN-20220301134145

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202759
Report Date: 02/01/2022
Date Signed: 02/01/2022 03:34:22 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
05/07/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20210507144107

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: 48	DATE:	02/01/2022
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	AIdah Tayag		TIME COMPLETED:	03:53 PM

ALLEGATION(S):

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Staff member hit resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted a complaint investigation visit to deliver investigation finding. LPA met with administrator (ADM) Aidah Tayag.

On 05/07/2021, the Department received a complaint about the above allegation. An investigation visit was conducted on 05/12/2021. ADM, R1, S2-S4 were interviewed. The rosters of current residents, R1's Physician report, R1's Appraisal Needs and Services Plan, and R1's Functional Capability form 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: 02/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022

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-20210507144107

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: 02/01/2022

NARRATIVE

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Staff member hit resident:
On 05/05/2021, the Department received an Incident Report from the facility regarding facility staff hit resident, and facility started to investigate.

On 05/06/2021 and 05/12/2021, LPA interviewed ADM. ADM stated the facility conducted interview investigation with two staff (S1 and S2). ADM stated S1 and S2 denied the allegation. ADM stated there were no staff observed nor heard staff hitting or physically abusing R1. ADM stated R1 was assessed but there were no discoloration, bruise, or skin tears were observed.

On 05/12/2021, and 05/17/2021, LPA interviewed staff (S1 - S4). All 4 staff denied allegation of hitting R1, and all of them stated they did not see or hear any staff physically abused R1.

On 05/17/2021, LPA interviewed resident R2. R2 stated R1 was unable to control R1's temper. R2 stated R1 had difficulties interacting with people. R2 stated R1 is impatient and and had episodes of outbursts.

On 05/17/2021, LPA interviewed R1's family member (FM). FM stated does not believe any facility staff hit R1. On 07/20/2021, LPA subsequently interviewed FM, FM stated R1 does not have any new complaint.

On 11/01/2021, LPA interviewed R1's doctor (D1). D1 stated D1 did not see any injuries, marks or bruising on R1's body when R1 told D1 that R1 got hit by facility staff during R1's doctor visit.

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: 02/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20210507144107

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: 02/01/2022

NARRATIVE

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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.

Exit interview conducted with 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: 02/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3