435202821-11-16-2023-26-AS-RMAO-CXTVKA-20231122153002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202821
Report Date: 11/16/2023
Date Signed: 11/16/2023 01:56:59 PM

Unfounded

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
03/08/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230308155736

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:	11/16/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Licensee Irish Ladwig		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident sustained bruises from falling but staff are not aware of injuries.
Facility is not providing activities for the residents.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Monter and Partoza conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with (LN) Licensee Irish Ladwig.

Resident sustained bruises from falling but staff are not aware of injuries.

The department review of Willow Oaks Senior Living internal fall report stated R1 had a witnessed fall on February 22, 2023, in the living room and after minor assistance R1 was able to walk without any discomfort. The report states R1’s Power of Attorney (POA) and doctor was informed about the fall. On a follow up report dated, February 23, 2023, R1 was assessed and was able to walk without pain and discomfort.

On March 15, 2023, LPA David Marrufo interviewed resident R1. R1 stated he/she “doesn’t believe in falling. I tripped. I did it and fixed it.” Based on R1’s physicians report, dated January 4, 2023, R1 is diagnosed with a neurocognitive disorder. Page 1 out of 3

Unfounded

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: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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 7

Control Number 26-AS-20230308155736

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: WILLOW OAKS SENIOR LIVING	FACILITY NUMBER: 435202821
	VISIT DATE: 11/16/2023

NARRATIVE

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On March 15, 2023, LPA David Marrufo interviewed R1’s Power of attorney, (POA). POA stated the following, “they called me as soon as R1 had a fall and called me and made a record of it. They checked R1 the next morning and there was no problem.” POA stated the facility staff informed him/her that R1 had a bad step and lost his/her balance.

On March 15, 2023, LPA Marrufo interviewed administrator (ADM) and Licensee (LN). ADM & LN stated R1 had a fall on February 22, 2023 & notified the POA regarding the fall and recorded it in internal records. ADM & LN stated it he/she wouldn’t describe it as a fall, but more of a trip and R1 only hit their knee. ADM stated the resident was assessed and no bruises or injury was observed. ADM stated R1 was assessed the following day as well, and no injury was observed.

On November 16, 2023, LPA's Monter and Partoza interviewed ADM regarding the fall. ADM re-enacted R1 stumbled and fell on his/her knee. ADM stated R1 lost balance due to losing her footing in the living room. ADM stated R1 then slowly fell on his/her knee and then laid on his/her side. ADM stated R1 then used the recliner next to him/her to lift themselves up.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Facility is not providing activities for the residents.

On March 8, 2023, the Department received a complaint alleging the facility is not providing activities for the residents.

On March 15, 2023, LPA Maruffo & Monter toured the facility. LPAs observed resident R1 participating in a puzzle activity in the morning and was later escorted with a staff member for a walk outside.

A review of Willow Oaks Senior Living’s Policy & Protocol for activities states the following: the ADM is responsible for planning the daily schedule for activities and residents are encouraged to contribute to the planning, preparation, and critique of planned activities. A monthly calendar of activities was observed during the visit.
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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: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 26-AS-20230308155736

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: WILLOW OAKS SENIOR LIVING	FACILITY NUMBER: 435202821
	VISIT DATE: 11/16/2023

NARRATIVE

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On March 15, 2023, LPA interviewed residents R1-R3. R1 stated the facility provides him/her with things to do. R2 stated he/she did not want to be interviewed. R3 is nonverbal and could not answer LPA’s questions.

On March 15, 2023, LPA interviewed R1’s Power of attorney, (POA). POA stated “they do provide activities for R1. The activities that they have is that they get together at the table and do scrabble. When the weather is nice, they walk R1. They do have activities. I have seen them walk R1.”

On March 15, 2023, LPA interviewed ADM, S1 and Licensee. ADM stated the facility does provide activities such as walking, television, scrabble, listening to music, and arranging flowers. S1 stated the facility provides activities for the residents. S1 stated they assist residents with walking by holding their hands. The licensee stated the facility provides multiple activities such as; watching television, bingo, cards, walking.

On November 16, 2023, LPA's Monter & Partoza interviewed R2, R4, R6-R8. R7 and R7 stated the facility does provide activities such as walking dominos, and bingo. R6 and R7 stated the facility does offer but they choose to to other things. R2 stated the home does have activities but he/she prefers to stay and watch television. R3 and R8 was unable to answer LPA questions due to inability to speak.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

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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: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 7

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
03/08/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230308155736

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:	5	CENSUS: 5	DATE:	11/16/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Licensee Irish Ladwig		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility locked facility bathroom preventing residents to use.

INVESTIGATION FINDINGS:

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On March 8, 2023 the Department received a complaint alleging the facility locks the facility bathroom preventing residents to use.

A review of R1’s physician’s report states R1 has a neurocognitive disorder. R1 has a fecal smearing behavior and is not able to care for his/her own toileting needs.

A review of R1’s Appraisal/Needs and services plan (ANS) dated December 23, 2022 states the following; R1 has rummaging behavior. R1 is resistant and combative during personal care that requires her maximum 2 person assist. ANS also states R1 digs out his/her own bowel movement & under method of evaluating progress the from states the facility will supervise resident at all times when he/she is going to the bathroom on her own. ANS states” Do not leave resident alone or unattended in the bathroom or shower.”

Page 1 out of 3.

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: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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 7

Control Number 26-AS-20230308155736

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: WILLOW OAKS SENIOR LIVING	FACILITY NUMBER: 435202821
	VISIT DATE: 11/16/2023

NARRATIVE

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On March 15, 2023, LPA David Marrufo interviewed R1’s Power of attorney, (POA). POA stated the following: “They generally lock the bathroom door. They check R1 about every hour or so.” POA added, “I know that on several times, R1 has been in there by himself/herself and took his/her pants off and put his/her feces all over the walls and that happened several times. That is the reason that they shut the door. R1 tries to get rid of his/her feces.” POA stated he/she gave verbal permission to lock the bathroom door.

On March 15, 2023, LPA interviewed ADM, S1, & Licensee. ADM and S1 stated R1’s bathroom was locked due to R1 “digging out feces and putting on the walls." 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 feces smearing that occurred in the first week. ADM and Licensee stated they had a verbal agreement with R1's family member regarding locking the bathroom door during the admission of R1.

On November 13, 2023 LPA interviewed R1’s POA. POA stated the facility locked R1’s bathroom door due to smearing behavior and to keep R1 out of that bathroom for his/her safety, and to keep him/her going to one bathroom.

On November 16, 2023, LPA's Monter and Partoza interviewed ADM and Licensee. ADM stated R1's behavior was an ongoing issue in the first occurred frequently. ADM stated the facility does not have a toileting log for R1. ADM stated the facility does not have a wake night staff. ADM stated that sometime when we are busy, that's when she's doing it, the smearing. ADM stated that the behaviors incidents regarding would eventually become once a week. ADM stated before R1 left the facility, R1 continued to have behaviors regarding hiding his/her feces and diaper. ADM stated the bathroom door was locked when R1 was unsupervised. ADM stated " we didn't want her to go to the bathroom alone." ADM stated " it didn't happen in the other bathroom because she was supervised." Licensee stated R1 did not smear in the other bathroom because some one was with him/her. Licensee and ADM stated R5 was agreeable to having the private bathroom door locked. Licensee stated the reason the facility locked the door was because R1 was washing their diapers in the toilet. Licensee stated he/she feared risks around water in the toilet bowel without supervision. Licensee stated the other bathrooms are available to R1.

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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: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 26-AS-20230308155736

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: WILLOW OAKS SENIOR LIVING	FACILITY NUMBER: 435202821
	VISIT DATE: 11/16/2023

NARRATIVE

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A review of the facility floor plan shows that R1’s bedroom is bedroom #1, which has a private bathroom. Bedroom #1 is a shared bedroom, for R1 and R5.

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.

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.

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. ADM also stated R1 would hide used toilet paper around his/her shared bedroom. ADM stated they have found R1's diaper hidden under R1's roommates bed.

The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

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. Page 3 out of 3.

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.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 26-AS-20230308155736

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: WILLOW OAKS SENIOR LIVING	FACILITY NUMBER: 435202821
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/23/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	ADM stated they will send a letter of understanding regarding the regulation to LPA by POC date, 11/23/2023.
	8 9 10 11 12 13 14	Based on interview and record review; R1’s lack of supervision and absence of care plan to address R1’s behavior leads to feces smearing, which is unsanitary for R1 and R5. This poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 11/23/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, ... that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by;	1 2 3 4 5 6 7	ADM stated they will send a letter of understanding regarding the regulation to LPA by POC date, 11/23/2023.
	8 9 10 11 12 13 14	Based on interview with ADM & LN; R1's shared bathroom was locked due to R1's behaviors. ADM & LN stated R1 had multiple instances of smearing when he/she was left unsupervised in bedroom #1's bathroom. This poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

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: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

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