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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202766
Report Date: 11/11/2023
Date Signed: 11/11/2023 11:59:26 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
06/09/2022 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20220609131252
FACILITY NAME:VILLA GLEN HOME ONEFACILITY NUMBER:
435202766
ADMINISTRATOR:TEODORO,ELVIE B.&DR.RIVERAFACILITY TYPE:
735
ADDRESS:1727 CURTNER AVE.TELEPHONE:
(408) 393-8075
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 5DATE:
11/11/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator Maria Marquez. TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff mismanages residents' medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA met with facility Administrator (ADM) Maria Marquez.

On June 9, 2022, the department received a complaint alleging staff mismanaged a resident’s medication. It has been alleged that a resident had gone 4 days without his/her medications.

On October 19, 2023, LPA Monter interviewed R1-R5. R4 & R5 stated the staff do not forget to hand out medications. LPA attempted to interview R1-R3, but residents were unable to answer LPA’s questions due to neurocognitive disorder.

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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 11/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2023
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 8
Control Number 26-AS-20220609131252
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: VILLA GLEN HOME ONE
FACILITY NUMBER: 435202766
VISIT DATE: 11/11/2023
NARRATIVE
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Based on a review of the facility’s centrally stored medication record for the months of May & June 2022 and a review of the medication administration record (MAR) showed the following. Resident R1-R6 medication records were reviewed, and 4 residents had 1-2 days of missing medications in the span of two months.

On October 19, 2023, LPA Monter randomly audited 3 residents medication records. LPA cross referenced residents’ medication bottles, centrally stored medication log and MAR. LPA did not find any discrepancies in 3 residents medication records.

On November 11,2023, LPA Monter interviewed S2 and ADM. S2 stated the staff always give the residents their medications. And if a box in the mar isn’t check, they might have just forgotten to check it on the MAR. ADM stated this was over a year and half ago, but the staff do give the medications. ADM stated the staff may have forgotten to sign, but ADM reiterated that the staff do give the medications.

Based on the interviews conducted with residents and staff & records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited, Exit interview conducted with Administrator, Maria Marquez and a copy of the report was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 11/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2023
LIC9099 (FAS) - (06/04)
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