435202768-8-7-2024-26-AS-RMAO-D8AH5G-20240819055329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202768
Report Date: 08/07/2024
Date Signed: 08/07/2024 10:10:01 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
06/01/2022 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20220601163556

FACILITY NAME:	VILLA GLEN HOME TWO		FACILITY NUMBER:	435202768
ADMINISTRATOR:	TEODORO,ELVIRA & DR.RIVERA		FACILITY TYPE:	735
ADDRESS:	2403 PEBBLE BEACH DR.		TELEPHONE:	(408) 393-8075
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	6	CENSUS:	DATE:	08/07/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Malu Marquez		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained injuries while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPA met with Administrator Maria Marquez.

On June 01, 2022, the Department received a complaint alleging a resident sustained injuries.

Based on a review of facility incident reports, on May 29, 2022, at 1:30pm, R1 suddenly stood up and ran to the bathroom. R1 exhibited self injurious behavior such as screaming, banging his/her hand on bathroom sink, and biting him/herself several times. Staff intervened/redirected R1 wherein R1 sustained a wound from his/her biting. Staff sought medical attention by taking R1 to the hospital. Furthermore, on May 30, 2022, the ADM received a call from the attending physician who stated R1 was admitted for observation and to prevent any infection.

Page 1 Out of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20220601163556

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 TWO	FACILITY NUMBER: 435202768
	VISIT DATE: 08/07/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on further investigation, on June 3, 2022, local law enforcement observed resident R1 was restrained on one side of the hospital bed in the hospital. A shift nurse stated R1’s right hand was retrained on the hospital bed railing because R1 was constantly trying to bite his/her arms. Local law enforcement also interviewed facility Administrator (ADM). ADM stated the facility does not use restraints. ADM stated the red marking's were from the hospital bandage that was wrapped around R1’s arm during the hospital visit.

On June 06, 2022, and September 21, 2023, LPA’s interviewed staff members S1-S4 and Administrator. 4 Out of 4 staff members interviewed, all staff denied the allegation that facility staff restrained R1 resulting to an injury. 4 Out of 4 staff members interviewed stated R1 has self injurious behavior, which includes biting him/herself.

On September 21, 2023, LPA Monter attempted to interview resident R1 at the facility. Due to R1’s developmental disability, R1 was not able to respond and/or provide information about the incident or injury sustained during interview.

On December 26, 2023, LPA Monter interviewed ADM Sloan. ADM stated R1 has self injurious behaviors such as biting him/herself. ADM stated he/she could not recall what exactly occurred on May 29, 2022 other than staff provided first aid to R1 and took R1 to the hospital. ADM stated R1’s bandage was put on by the hospital nurse [not by the facility]. ADM denied that the facility staff restrained R1 or residents at the facility.

On July 9, 2024, LPA Monter interviewed staff S2. S2 stated he/she does not remember working with R1 or what had occurred on May 29, 2022. S2 stated that the facility did have staff supervising the residents but cannot remember as it was a long time ago.

A review of R1’s Appraisal/Needs & Services Plan (ANS), dated August 25, 2022, states that R1 engages in self injurious behaviors where he/she will bite him/herself resulting in an injury or wound. R1 will also attempt to bite his/her flesh and not allow his/her wound/injury to heal.

A review of R1’s Individual Program Plan (IPP), dated June 27, 2023, states R1 has self injurious behavior such as scratching/biting an existing wound. The IPP also states R1 will decrease the frequency of maladaptive behaviors including self injurious behavior.
Page 2 Out of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 26-AS-20220601163556

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 TWO	FACILITY NUMBER: 435202768
	VISIT DATE: 08/07/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The department reviewed R1’s self injurious behavior tracker. R1 had 22 instances of self injurious behavior for the month of March 2022. R1 had 17 instances of self injurious behavior for the month of April 2022. R1 had 28 instances of self injurious behavior for the month of May 2022.

Based on a review of the facility direct care staff schedule, S6 was scheduled as R1’s 1:1 staff on May 29, 2022.

The Department attempted to interview the staff S5 and S6 for additional information but was unable to get in contact with these staff members.

Based on investigation, records reviewed, and interviews conducted, 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 nor disprove that resident R1 had sustained injuries from allegedly being restrained or neglect/lack of supervision.

No Deficiencies cited under California Code of Regulations Title 22. This Report was reviewed by Administrator Maria Marquez.

Page 3 Out of 3

END OF REPORT.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 6