435202821-11-14-2024-26-AS-KHOS-DBCRJ9-20241125120333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202821
Report Date: 11/14/2024
Date Signed: 11/14/2024 03:56:20 PM

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
06/09/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230609105059

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: 6	DATE:	11/14/2024
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Administrator Agnes Teodoro		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff did not ensure a resident is regularly observed for changes in physical health condition
Facility staff did not provide immediate medical assistance to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Administrator Agnes Teodoro

On June 9, 2023, the Department received a complaint alleging Facility staff did not ensure a resident is regularly observed for changes in physical condition/ Facility staff did not provide immediate medical assistance to resident.

On May 22, 2023, the Department received an incident report (IR) that stated, on May 20, 2023, staff observed R1 had no appetite for food, but was able to drink small amounts of liquid. The IR stated, on May 21, 2023 R1 was taken to breakfast and R1 at 80% of his/her meal. Furthermore, the IR stated at 11:30am R1 refused to eat and drink. The IR states the facility called an ambulance and R1 was taken to the emergency room. The IR also states on May 21, 2023, at 6:40pm, the facility was informed that R1 had a Urinary Tract Infection. (UTI). Page 1 Out of 3.

Unsubstantiated

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: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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 5

Control Number 26-AS-20230609105059

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: 11/14/2024

NARRATIVE

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On June 16, 2024, LPA David Marrufo interviewed ADM. ADM stated R1 had changes in his/her conditions on May 20, 2023. ADM stated on May 21, R1 started to refuse food and at lunch time R1 didn’t want to eat anymore. ADM stated R1 went to the emergency room. ADM noted R1 was not complaining about any abdominal pain. ADM stated he/she notified R1’s physician and R1’s Power of Attorney (POA). ADM stated after two days the facility was informed R1 had a UTI and was transferred to a rehab center.

On October 30, 2024, LPA Monter interview staff S1 and S2. Both staff interviewed stated if they see any change to a resident’s condition or baseline, they will inform the ADM about said changes. Both staff interviewed stated they have been working at the facility for 7 months and did not work with R1.

LPA interviewed ADM. ADM stated she works at the facility 5 days a week, 8 hours a day. ADM stated she was the one who noticed the change in condition regarding R1. ADM stated she informed R1’s doctor and R1’s POA. ADM stated she called for an ambulance for R1 to be checked. ADM also stated her staff inform her of any changes in the residents’ conditions.

Based on a review of R1’s progress notes (PN), on May 14, 2023, R1 has not had a bowel movement. PN stated Medications and prune juice given to manage, but ineffective. Resident R1’s physician was notified and R1’s family members. On May 15, 2023, R1 still has not had a bowel movement & R1’s physician and family members were notified. Facility received a call from clinic stating physician assistant would arrive and administer suppository. R1 had a bowl movement later that evening.

Based on a review of R1’s PN, On May 21, 2023, R1 refused to drink liquids at 7:30am. At 11:30am, R1 refused to eat and drink liquids. R1’s doctor and POA was notified. A facetime call done with nurse who assessed R1. The Nurse recommended to take R1 to urgent care/ ER for evaluation. R1’s POA notified and agreed to send R1 to ER. The facility received a call and was informed about R1’s Urinary tract infection. On May 22, 2023, the facility received a call from the hospital and was informed that R1 had been treated for sepsis (bladder infection) and was not ready to come back to the facility.

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: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20230609105059

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: 11/14/2024

NARRATIVE

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Based on a review of R1’s Physician’s Report, dated January 4, 2023, R1 has a neurocognitive disorder. The report states R1 is incontinent in both bladder and bowel. The Report also states R1 is able to communicate his/her needs and is able to feed him/herself.

According to Mayo Clinic (https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447), UTIs don't always cause symptoms…In older adults, UTIs may be overlooked or mistaken for other conditions.

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 that the allegations did or did not occur.

Page 3 Out of 3. END OF REPORT.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
06/09/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230609105059

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: 6	DATE:	11/14/2024
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Administrator Agnes Teodoro		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility retained a non-hospice resident who depends on all activities of daily living.

INVESTIGATION FINDINGS:

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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: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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 5

Control Number 26-AS-20230609105059

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: 11/14/2024

NARRATIVE

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On June 16, 2024, the Department conducted an initial investigation. Resident R1 was no longer living at the facility, and resident R7 was the new resident to the facility.

On November 14, 2024, LPA interviewed ADM and Licensee (LN). ADM and LN stated R1 and R4 can walk and eat by themselves. ADM and LN stated R1 and R4 can also reposition themselves in bed and are able to do Activities of Daily Living (ADL’s) with staff assistance. ADM and LN stated R2 and R3 can eat by themselves and can reposition themselves in bed. ADM and LN stated residents R5-R7 were hospice residents. ADM and LN stated R6 and R7 were still able to feed themselves.

A review of R1’s Functional capabilities form, dated March 20, 2023, R1 is ambulatory and able to transfer in and out of bed. A review of R1’s physicians report, dated January 4, 2023, states R1 is able to feed him/herself.

A review of R2’s Physicians Report, dated June 5, 2023, states R2 does not require continuous bed care. R2 is able to feed him/herself using special equipment to hold spoons and forks. R2’s Functional Capability Assessment (FCA) dated September 20, 2023, states R1 is able to reposition from side to side. The FCA also states R2 uses a wheelchair.

A review of R3’s physicians report dated June 27, 2024, R3 is able to feed him/herself and does not requires continuous bed care. R1’s Functional Capability assessment, dated September 8, 2022, states R3 is able to eat by him/herself.

A review of R4’s needs and services plan, dated April 19, 2023, R4 is able to feed him/herself. A review of R4’s Functional capabilities form, dated April 25, 2023, states R4 is able to walk with a walker and is able to reposition him/her self from side to side, and is able to feed him/herself.

A review of R5, R6 & R7’s facility file shows these 3 residents were in hospice.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records 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. Page 2 Out of 2

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC9099 (FAS) - (06/04)

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