435202759-2-12-2024-26-AS-KHOS-D36LYB-20240308081004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202759
Report Date: 02/12/2024
Date Signed: 02/12/2024 05:08:47 PM

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
04/05/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220405164117

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:	02/12/2024
		UNANNOUNCED	TIME BEGAN:	03:35 PM
MET WITH:	Aidah Tayag		TIME COMPLETED:	04:36 PM

ALLEGATION(S):

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Resident is not provided an adequate amount of showers.
Resident was left soiled for a long period of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Administrator (ADM) Aidah Tayag.

On 04/05/2022, the Department received an complaint with the above allegations.

On 04/12/2022, the Department conducted an initial investigation visit. LPA interviewed Administrator and 2two residents (R1, R2). LPA obtained Resident Physician report, Appraisal Needs and Services Plan, showering schedule and Admission Agreement.

Continue on LIC9099-C. Page 1 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: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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 3

Control Number 26-AS-20220405164117

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: 02/12/2024

NARRATIVE

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Resident is not provided an adequate amount of showers:
Resident was left soiled for a long period of time:

On 04/12/2022, LPA interviewed Administrator (ADM) Aidah Tayag. ADM stated the facility policy is that, by default, the residents are scheduled 2 times for showers per week with caregivers' help, however, if the residents need more than 2 times and requested, then the facility will provide the shower service by as needed basis. ADM stated if the residents need more showers regularly, then the facility will discuss with resident's family members to modify the admission agreement/service plan. ADM stated the facility caregivers check the residents' diapers every two hours. ADM stated the facility caregivers always come to help residents if the residents need to change diaper and requested for help.

LPA interviewed 4 resident (R1 - R4). R1 stated he/she takes showers two times per week with caregivers' help. R1 stated that he/she thought it should be more often for shower, for example, at least 3 times, but he/she did not request for it. R1 stated the caregivers came to check his/her diaper every two hours. R1 stated the caregivers always came to help when he/she requested help to change diaper. R1 stated caregivers help him/her with laundry one time per week. R1 stated the laundry could be more often, but he/she did not request for it. R2 stated he/she had 3 showers per week because he/she requested one more shower per week, and he/she did not need help for changing diaper. R3 stated originally, he/she had a shower every 3 days and later he/she had a shower every 2 days because he/she requested to have more showers per week. R3 stated he/she did not wear diaper, but the facility caregivers checked him/her every two hours. R4 stated he/she had 2 showers per week, and he/she thought that was enough for him/her. R4 stated he/she did not wear diapers at day time but wears diaper at night time but the caregiver checked him/her every two hours.

LPA interviewed 2 staff. 2 out of 2 staff stated the residents receive at least two showers per week, and the caregivers checked residents every two hours and changed resident's diaper if needed. S1 emphasized that the residents can request more showers.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220405164117

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: 02/12/2024

NARRATIVE

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Based on the interviews, the residents received at least two times showers per week and residents can request more showers if needed. Staff checked residents every two hours and changed the diaper if needed. 4 out of 4 residents did not complain the services of the facility.

Based on the residents' shower schedule, each resident received at least two showers per week.

The Department has investigated the above allegations. Based on interviews conducted and documents reviewed, the Department found that the above allegations are 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 was conducted with ADM. This report was provided for signature. A copy of this report was provided to ADM.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3