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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202780
Report Date: 06/22/2022
Date Signed: 06/22/2022 04:18:42 PM

Substantiated


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
05/04/2022 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20220504134836
FACILITY NAME:SONNET HILLFACILITY NUMBER:
435202780
ADMINISTRATOR:HAHKLOTUBBE, DAVIDFACILITY TYPE:
740
ADDRESS:429 MERIDIAN AVETELEPHONE:
(408) 731-0019
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:80CENSUS: 17DATE:
06/22/2022
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Jasmine LatuTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility failed to seek medical attention for resident
Facility refused to accept client back from hospital
Administrator not Qualified
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Jasmine Latu.

On 05/04/2022, the Department received a complaint with the above allegations. The Department conducted facility visits on 06/02/2022. The Department interviewed 7 staff plus the Administrator (Admin). The Department also conducted interviews with 5 responsible parties of residents and one medical professional. The Department obtained copies of resident records and communications between the facility staff and resident R1’s responsible person (RP1).

On 04/27/2022, the Department received an Unusual Incident/Injury (UIR) Report dated 4/27/2022 stating that R1 was transported to a hospital for showing signs of distress and not eating or drinking starting 04/25/2022.

See LIC9099-C for more information. Page 1 of 5.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
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 7
Control Number 26-AS-20220504134836
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: SONNET HILL
FACILITY NUMBER: 435202780
VISIT DATE: 06/22/2022
NARRATIVE
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Between 4/26/2022 through 6/2/2022, 7 staff were interviewed. 6 out of 7 stated R1 was observed to be weak, not wanting to get out of bed, went 24-48 hours without eating and constipated for two days prior to being sent out to the hospital. 1 staff stated R1’s doctor/nurse practitioner (NP) was contacted on the day when R1 was sent out to the hospital.

R1’s nurse practitioner (NP) was interviewed and stated facility left a voicemail on 4/25/2022 stating R1 had not had a bowel movement or eaten in 48 hours. When NP called back, R1 was already at the hospital.

A copy of R1’s Medication Administration Record (MAR) was obtained. The review of the MAR noted the entry for 04/23/2022 stated R1 was given medications (names of meds not stated) in the morning, at 4PM, and 8PM. The entry for 04/24/2022 stated R1 was given medications (no names of meds stated) in the morning, but not at 4PM or 8PM. There was a handwritten note on the entry that stated: “Pauline was not eating. We did not give meds bc of this. Just giving fluids.”

R1’s Documentation Survey Report for April 2022 includes a Meal Consumption log was obtained and reviewed. The entry for 04/21/2022 stated R1 ate 75%-100% at 8AM, 12PM, and 5PM. The entry for 04/22/2022 stated R1 refused meal consumption at 8AM; there was no entry for 12PM; the 5PM entry stated R1 consumed 75%-100% of a meal. The entry for 04/23/2022 has no entry for 8AM and 12PM; the 5PM entry stated R1 ate 75%-100% of a meal. The entry for 04/24/2022 stated R1 refused meals at 8AM and 12PM and ate 0-25% of a meal at 5PM. There was no documentation from R1’s doctor/NP to order medications be stopped due to not eating. Neither was there documentation that R1’s POA was notified regarding R1 not eating for 48 hours.

A copy of R1’s LIC602 Physician’s Report was reviewed and noted R1 has a diagnosis of dementia and type II diabetes and has bowel and bladder impairment. It was noted that R1 is able to feed self, but meal set up is needed.

On 04/26/2022, Admin called Licensing Program Analyst (LPA) stating that Admin had conducted a reassessment of R1 over the telephone with hospital personnel and that given R1’s fecal condition and the need for acute care for R1’s diabetes, the facility staff cannot assist R1.

See LIC9099-C for more information. Page 2 of 5.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20220504134836
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: SONNET HILL
FACILITY NUMBER: 435202780
VISIT DATE: 06/22/2022
NARRATIVE
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The review of UIR dated 4/27/2022 noted R1 was sent to the hospital on 04/25/2022 and the facility and R1’s NP agreed that the facility is not able to ensure R1’s safety and will not be receiving R1 back into the facility.

During interview, NP stated that Admin called NP on 04/26/2022 to get an update on R1’s condition. NP stated to have not had an update on R1’s condition at the time because R1 was still at the hospital. Admin stated to NP that the facility would not be accepting R1 back to the facility due to nonpayment and communication issue with family. NP stated Admin did not ask NP for NP’s opinion and did not discuss R1’s medical conditions as being the reason for R1 not returning to the facility.

A copy of an email communications between Admin and R1’s responsible party (RP1) dated 04/27/2022 was obtained, reviewed and noted Admin stated that the hospital, NP, and Admin have collectively determined that R1’s recent incident of a fecal impaction and significant drop in blood sugar result in R1’s care exceeding that which the facility can offer, and as a result, the facility will no longer be accepting R1 back to the facility.

On 5/11/2022, RP1 was interviewed and stated per hospital staff, on 04/27/2022, Admin notified the hospital that the facility would not be allowing R1 to return to the facility due to financial reasons.

Attempts were made to reach out to the hospital staff, but hospital staff did not return calls.

A copy of the 30-day eviction notice dated 02/10/2022 was reviewed and noted this eviction notice did not meet Title 22 requirement as it contained only the reason and no other components and therefore is determined as not valid. The department has not received a copy of this eviction notice in February 2022.

No discharge summary report was produced for review.

See LIC9099-C for more information. Page 3 of 5.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20220504134836
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: SONNET HILL
FACILITY NUMBER: 435202780
VISIT DATE: 06/22/2022
NARRATIVE
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RP1 interviewed stated that on 04/27/2022 after RP1 was notified that R1 would not be allowed to return to facility, RP1 arrived at the facility, but staff would not allow RP1 to enter the facility. Admin arrived shortly at the facility and Admin refused to discuss this matter in the facility but insisted that they talked in the parking lot. RP1 stated Admin was unprofessional, accusatory, verbally abusive, and threatened to put RP1 behind bars.

Admin was interviewed and confirmed that on 4/27/2022, Admin and RP1 had an argument in the parking lot. RP1 demanded the facility to re-accept R1 from the hospital. There was an exchange of accusations and Admin admitted that Admin told RP1 that RP1 could go to prison for the federal offense of not paying R1’s bills. Admin also admitted to directing front desk staff to not let RP1 in the facility.

Facility did not produce any documentation or record of a restraining order against RP1.

Staff S4 who was covering front desk on 4/27/2022 was interviewed and admitted instructing the maintenance staff to keep the door locked. S4 stated to have not witnessed the encounter between Admin and RP1 and that the facility surveillance cameras did not capture the encounter as it occurred out of view of the cameras.

The review of email communications and interviews conducted noted that Admin made statements that were inaccurate. Admin’s statement regarding NP and Community Care Licensing collectively supported his decision on not taking R1 back were inaccurate. On 4/26/2022 Admin notified NP and LPA on his decision of not taking R1 back. LPA had advised to obtain an assessment prior to issuing eviction notice and did not approve of an eviction as purported. NP had confirmed there was no discussion or agreement with Admin regarding R1 returning.

Admin issued a 30-day eviction notice on 2/20/2022 which the Department obtained during the investigation. The review of this eviction notice noted it to be invalid.

Facility was unable to produce a copy of R1’s admission agreement when requested. Admin admitted his mistake of giving the original copy to RP1 and stated RP1 never returned it.

See LIC9099-C for more information. Page 4 of 5 .
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 26-AS-20220504134836
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: SONNET HILL
FACILITY NUMBER: 435202780
VISIT DATE: 06/22/2022
NARRATIVE
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RP1 was interviewed and stated there was no admission agreement but only a copy of the room reservation agreement was given.

A copy of the reservation agreement dated 7/30/2021 was obtained from RP1 and reviewed. It was noted that facility failed to comply with the facility’s own guideline and protocol as stated on the reservation agreement. It was stipulated on the reservation agreement that “upon successful completion of my personal needs assessment, I understand that I will be required to sign a residency agreement… prior to my Occupancy date.” R1 moved in on 10/5/2021 and sent to the hospital on 4/25/2022. During these six months, no admission agreement was completed by Admin for R1.

Based on records review and interviews, there is preponderance of evidence to prove the alleged violations did occur, therefore the allegations are substantiated.

See LIC9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Jasmine Latu and a copy of this report and appeal rights were provided.


Page 5 of 5.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20220504134836
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: SONNET HILL
FACILITY NUMBER: 435202780
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2022
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Licensee agrees to create a plan to train staff reporting changes in resident conditions to resident's primary care physician and responsible party by POC date. Once trainings are completed, training records shall be submitted to CCLD.
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This requirement was not being met as evidenced by:
Based on interview and record review, there was no documentation that facility brought to the attention of R1’s physician prior to stopping R1’s medications when R1 was not eating. Facility also did not inform R1’s responsible person when R1 was not eating for 48 hours. This poses an immediate threat to the health and safety of the resident in care.
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Type B
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Section Cited
CCR
87668.2(a)(20)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents. For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident.
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Licensee agrees to submit a plan to train relevant staff on reasons for issuing an eviction notice to residents that are permitted by state laws and regulations by POC date. The training records shall be submitted to CCLD once completed.
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This requirement is not being met as evidenced by:
Based on interview and record review, facility initiated the involuntary discharge of R1 by refusing to take R1 back from the hospital without a proper eviction notice and without discussion with all parties involved. This poses a potential risk to the personal right of the resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 26-AS-20220504134836
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: SONNET HILL
FACILITY NUMBER: 435202780
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2022
Section Cited
CCR
87405(d)(2)
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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
This requirement was not being met as evidenced by:
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Licensee agrees to train relevent facility staff on proper eviction procedures and eviction notices to residents and families, interpersonal professionalism training, and proper admission procedures and agreements. These training plans shall be
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Based on interview and record review, Admin failed to have knowledge of and ability to conform to Title 22 on eviction procedures, personal rights and admission agreement as R1 was not given the proper eviction notice, the eviction notice was not sent to licensing agency, admission agreement was not completed, involuntary discharge and unprofessionalism in dealing with a family member. This poses an immediate risk to the health and safety of residents in care.
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submitted to CCL by POC date. Once trainings are completed, training records shall be submitted to CCL.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7