435202820-4-4-2024-26-AS-KHOS-D4CK3Q-20240415073308

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202820
Report Date: 04/04/2024
Date Signed: 04/04/2024 02:31:38 PM

Substantiated

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
10/27/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20231027154225

FACILITY NAME:	WHITE OAKS SENIOR LIVING		FACILITY NUMBER:	435202820
ADMINISTRATOR:	LADWIG, IRISH		FACILITY TYPE:	740
ADDRESS:	1680 WHITE OAKS RD.		TELEPHONE:	(408) 821-2630
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	6	CENSUS: 5	DATE:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Administrator Irish Ladwig		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Facility accepted residents with a prohibited condition
Staff are sleeping in the garage

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Manuel Monter and Mita Partoza conducted an unannounced visit to deliver findings regarding the allegations listed above. LPA met with Administrator (ADM) Irish Ladwig.

Staff are sleeping in the garage.

On November 3, 2023, the Department investigated a complaint allegation that staff are sleeping in the garage.

During inspection of the facility garage, LPA observed a twin bed with pillow and blanket located on left side of garage directly next to the garage’s window. LPA also observed clothes hanging on coat hangers above the bed and other personal belongings such as jeans, shirts, and sweaters. LPA also observed a plastic storage cabinet with cloths inside. LPA took pictures of the inside of the garage during tour with staff S1.
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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20231027154225

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: WHITE OAKS SENIOR LIVING	FACILITY NUMBER: 435202820
	VISIT DATE: 04/04/2024

NARRATIVE

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LPA Monter interviewed staff (S1 and S2) and ADM regarding the allegation that staff are sleeping in the garage. ADM stated no one sleeps in the garage and staff do not sleep there.

Based on interview with staff (S1), S1 admitted and confirmed that he/she sleeps in the garage. S1 also reaffirmed that the picture taken was where he/she sleeps.

On April 04, 2024, LPA Monter and Partoza interviewed S3. S3 stated in November/October 2023 a staff member was sleeping in the garage.

Based on interviews, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.

This report was reviewed with Administrator Irish Ladwig, and a copy of the report was provided. Appeal Rights was provided.

Facility accepted residents with a prohibited condition.

On November 3, 2023, the Department investigated on an allegation that the facility accepted a resident with a prohibited condition (G-tube).

LPA Monter interviewed S1 and S2 who stated that R1 has G-tube.

LPA interviewed resident R1. R1 stated he/she just moved back to the facility in October 2023 after hospitalization. R1 stated the after-hospital discharge, he/she has G-tube which will be remain in place at the recommendation of R1’s physician.

LPA interviewed ADM. ADM stated he/she only has one resident who has the G-tube. ADM stated when R1 came back to the facility on October 2023, he/she had a G-tube. Page 2 Out of 3

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20231027154225

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: WHITE OAKS SENIOR LIVING	FACILITY NUMBER: 435202820
	VISIT DATE: 04/04/2024

NARRATIVE

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On November 22, 2023, LPA Monter interviewed Witness 1 (W1). W1 stated, R1 moved back to White Oaks Senior Living on October 2023, with the G-tube. W1 stated R1 still has the G-tube until this day because it was recommended to keep it there in case R1 begins to worsen again.

On November 16, 2023, the Department received a request from the ADM requesting for an exception for R1 with G-tube. The exception request was made after the complaint allegation was filed on 11/3/2023.

Based on interviews, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.

This report was reviewed with Administrator Irish Ladwig and a copy of the report was provided. Appeal Rights was provided.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20231027154225

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: WHITE OAKS SENIOR LIVING	FACILITY NUMBER: 435202820
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/05/2024 Section Cited CCR 87615(a)(2)	1 2 3 4 5 6 7	87615 Prohibited Health Conditions (a) Persons who require health services... health condition including, but not limited to,... shall not be admitted or retained in a residential care facility for the elderly… (2) Gastrostomy tubes. This requirement was not met as evidence by:	1 2 3 4 5 6 7	ADM stated he/she will send a letter of understanding regarding the regulation. ADM has also already request and had her exception request approved.
	8 9 10 11 12 13 14	Based on interviews and record reviews, the ADM admitted a resident with G-tube in October 2023, without an exception. This poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 04/11/2024 Section Cited CCR 87202(a)	1 2 3 4 5 6 7	87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal… This requirement was not met as evidence by:	1 2 3 4 5 6 7	ADM stated he/she will send LPA photo documentation showing the garage is no longer being used as a sleeping area.
	8 9 10 11 12 13 14	Based on observations and interviews conducted. S1 admitted that he/she sleeps in the garage. S3 admitted a staff member was sleeping in the garage. Based on physical plant, the garage is not listed as a sleeping quarters for staff.	8 9 10 11 12 13 14	ADM stated he/she will also send a letter of understanding stating no staff or any individual is allowed to sleep in the following areas without building permit and fire clearance such as the garage.

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: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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