435202821-11-20-2023-26-AS-MMOR-CXS33S-20231120165403

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202821
Report Date: 11/20/2023
Date Signed: 11/20/2023 04:55:33 PM

Document Has Been Signed on 11/20/2023 04:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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:	WILLOW OAKS SENIOR LIVING		FACILITY NUMBER:	435202821
ADMINISTRATOR:	AGNES TEODORO		FACILITY TYPE:	740
ADDRESS:	1573 WILLOW OAKS DR.		TELEPHONE:	(408) 914-1147
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY: 6		CENSUS: 5	DATE:	11/20/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Licensee Irish Ladwig		TIME COMPLETED:	05:15 PM

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	Licensing Program Analyst Manuel Monter & Mita Partoza conducted an unannounced case management to amend a complaint investigation LIC9099 and LIC9099-D issued on November 16, 2023.(26-AS-20230308155736) LPAs met with (LN) Licensee Irish Ladwig explained the purpose of the visit. On March 15 & November 16, 2023, LPAs interviewed ADM, S1 and Licensee (LN). ADM, LN and S1 stated R1’s shared bathroom was locked due to R1’s fecal smearing behavior. Staff also stated, although R1’s shared bathroom was locked, he/she still had access to the other two bathrooms with supervision. ADM also stated that they found R1's clothes in shower and staff feared fall risk at night. ADM stated R1 would hide used toilet paper around his/her bedroom. ADM stated they have found R1's diaper hidden under his/her roommate’s bed. The licensee stated R1's bathroom is locked, due to R1’s behaviors. Based on a review of R1’s physician’s Report January 4, 2023, R1 has a neurocognitive disorder. R1 is incontinent on both bowel and bladder. Furthermore, under ‘mental condition,’ R1 has fecal smearing behavior and wandering behavior. R1 requires assistance with ADLs such as, but not limited to bathing and toileting. Based on a review of R1’s Appraisal/Needs and Services plan, LIC625 dated December 23, 2022, R1 has a rummaging behavior evidenced by digging though cabinet drawers, bathroom and taking items from one place and hiding them all over the house. R1 also had a behavior of by digging out his/her bowel movement through his/her undergarment. In addition, ADM also noted on LIC625 that R1 requires a toilet scheduling every 2-3 hours and R1 needs to be supervised when he/she enters the bathroom on his/her own at all times. Page 1 out of 3.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: WILLOW OAKS SENIOR LIVING	FACILITY NUMBER: 435202821
	VISIT DATE: 11/20/2023

NARRATIVE

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ADM and staff stated R1 has been found smearing early hours of the morning. ADM stated the facility does not have an awake night staff. A review of the facility’s LIC500 dated September 25, 2023, shows there is no wake night staff. Further review of R1’s LIC625, the ADM’s objective plan under the following areas “Mental, Physical/Health, functioning skills” does not address R1’s behaviors. ADM wrote under “evaluating progress,” the facility staff is to put R1 in a toileting schedule and supervise R1 when he/she is going to the bathroom on his/her own.

According to Title 22 code of regulations, 87625 Managed incontinence (a) The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances…(B) a structured bowel and/or bladder retraining program to assist the resident in restoring a normal pattern of continence. (C) a program of scheduled toileting at regular intervals. A review of R1’s file does reveal the facility did not have documentation on R1’s toileting. ADM stated that they do not have a log on toileting and notes regarding R1 behavioral episodes.

In addition, a review of R1’s LIC625, locking of R1’s shared bathroom (located in bedroom #1, based on the floor plan) is not written on the agreed upon plan, dated December 23, 2022.

Based on interview staff S1 and ADM, staff interviewed were unable to provide of how they are adhering to the plan in place. Staff were not aware of the toileting plan and always supervise R1 when he/she goes to the bathroom on his/her own.

Based on interview with ADM, there is no awake night staff and there is no toileting log. ADM and licensee stated R1’s shared bathroom was locked as a solution to prevent resident from smearing feces which also violates R1 and R5’s personal rights under code section 87468.1(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. R1 shared a bedroom with R5. Staff stated that R5 gave permission to lock bathroom. R1 has neurocognitive disorder.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: WILLOW OAKS SENIOR LIVING	FACILITY NUMBER: 435202821
	VISIT DATE: 11/20/2023

NARRATIVE

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ADM stated, “…sometimes when we are busy, that's when he/she’s doing it, the smearing.” ADM stated that R1 behaviors occurs during sleeping hours. Staff stated that they would at times hear movements from R1’s bedroom, and also during waking hours at 6:30AM wherein R1 was found with feces in bed, clothing and bedroom walls. ADM stated the smearing behavior always happened when he/she was alone.

Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Licensee Irish Ladwig and a signed copy of this report was provided along with appeal rights.

On 11/20/2023, at approximately 4:45pm. The report was presented to the Licensee and Licensee refused to sign. A copy of the report was printed and was handed to ADM. Appeal rights were printed and handed to ADM.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 11/20/2023 04:55 PM - It Cannot Be Edited

Created By: Manuel Monter On 11/20/2023 at 02:56 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: WILLOW OAKS SENIOR LIVING	FACILITY NUMBER: 435202821
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 11/27/2023 Section Cited	1 2 3 4 5 6 7	87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate... This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Based on a review of R1’s LIC625, R1 has a rummaging, wandering behavior& incontinence wherein R1 smears his/her feces on bathroom walls and self. R1’s behavior has not been addressed other than locking R1’s bathroom. The facility locking the bathroom door was not written on the plan of care.	8 9 10 11 12 13 14
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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:

Romeo Manzano

LICENSING EVALUATOR NAME:

Manuel Monter

LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC809 (FAS) - (06/04)

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