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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202822
Report Date: 08/20/2024
Date Signed: 08/20/2024 04:29:33 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
04/29/2022 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20220429161605
FACILITY NAME:HILLSDALE SENIOR LIVINGFACILITY NUMBER:
435202822
ADMINISTRATOR:LADWIG, JUSTINFACILITY TYPE:
740
ADDRESS:1538 HILLSDALE AVE.TELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 5DATE:
08/20/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Licensee, Irish LadwigTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
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9
Facility not following care plan.
Facility not serving quality food.
Resident's needs are not being met.
Not enough activities provided for residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
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13
Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Licensee, Irish Ladwig and stated the purpose of the visit.

On 4/29/2022, the Department received a complaint with the above allegations. On 5/6/2022, the Department conducted the initial investigation. On 8/29/2022, the Department continued their investigation.

Coninutation on LIC 9099-C, Page 1 of 4.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
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 6
Control Number 26-AS-20220429161605
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: HILLSDALE SENIOR LIVING
FACILITY NUMBER: 435202822
VISIT DATE: 08/20/2024
NARRATIVE
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Page 2 of 4.
Facility not following care plan/ Resident’s needs are not being met.
It was alleged that R1 is bedridden, and the staff do not come in a check on the resident to reposition R1. It was alleged R1 needs pillow to support his/her back based on Physical Therapy’s recommendation but staff forget to place a pillow on R1’s back.

On 5/6/2022, the Department interviewed Administrator (ADM), Licensee and staff S1. 3 Out of 3 staff stated the facility follows the R1's care plan and they try their best to meet the resident’s needs. 3 Out of 3 staff stated they check on R1 and reposition R1.

Based on record review of R1’s Appraisal/Needs and Services Plan dated 8/9/2021, the facility will “perform regular intentional rounding to assess need for position change, pain assessment, personal needs” and “provide assistance as needed e.g. positioning, feeling”. R1 is non-ambulatory and needs 2-person assistance or mechanical lift during transfers or when out of bed. R1 needs help with bathing and personal hygiene.

During today’s visit, the Department interviewed 3 staff (S2-S4) and 2 residents (R2-R3). 1 Out of 3 staff was working at the time of the initial complaint investigation. Staff S4 stated the staff checked on R1 every hour while R1 was awake during the day. S4 stated the staff would place a pillow on the back to prevent pressure injuries but resident would remove the pillow when resident was upset and used the pillow to throw it at the staff. 2 Out of 2 residents stated the staff provide care and meet their needs and do not have issues with the staff because they are providing the care the residents need at the facility. R2 and R3 stated the staff respond quickly when residents require assistance or help and check on the residents in a timely manner.

Facility not serving quality food.
On 5/6/2022, the Department conducted interviews with 6 residents. 6 Out of 6 residents (R1-R6) stated the food quality is “good” and “okay”. R5 stated the food is sometimes good, but not always good.

On 5/6/2022, the Department conducted an interview with Administrator (ADM), Licensee and Staff S1. ADM stated the facility does not post the food menu every week, but they follow a reference menu to prepare the food.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20220429161605
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: HILLSDALE SENIOR LIVING
FACILITY NUMBER: 435202822
VISIT DATE: 08/20/2024
NARRATIVE
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Page 3 of 4.
On 5/6/2022, LPA Steve observed fresh fruit in the kitchen.

On 8/23/2022, the Reporting Party (RP) shared a text message thread between Resident R1 and R1’s friend. R1 stated he/she did not like the salad provided and thought the soup was lumpy. R1’s friend responded stated R1 did not like the salad because “maybe it is too hard for [her/him] to eat”.

On 8/29/2022, the Department interviewed Administrator (ADM) who stated they do their best to accommodate to everyone’s food preferences and normally they have soup, salad, cake and an entree (example, pasta).

Based on facility food menu, residents are served different choices during each meal service with multiple options if residents do not prefer the meal served. During breakfast service, residents have multiple options from eggs, pancakes, oatmeal, cereal, and fruit plate, which can come with sides of bacon, sausages, biscuits, and fruits. During lunch service, residents have multiple options of salads to choose from and variety of pork, beef, and fish entrees. During dinner service, residents have multiple options of soup to choose from and a variety of pasta and sandwich entrees.

Not enough activities provided for residents.
On 5/6/2022, the Department conducted interviews with 6 residents. 3 Out of 6 residents don’t remember if facility provides activities for residents regularly. R3 stated the activities are “Okay” and R5 stated the facility does not provide activities.

On 5/6/2022, the Department interviewed Administrator (ADM), Licensee and staff S1. 3 Out of 3 staff stated the facility staff do not post the activities monthly, but the facility does provide the activities to residents.

On 8/29/2022, the Department interviewed S1. S1 stated the staff encourage R1 to be in the living room for activities and socialization, but R1 will insult the other residents. The staff will do 1:1 activity with R1 instead of a group setting.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20220429161605
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: HILLSDALE SENIOR LIVING
FACILITY NUMBER: 435202822
VISIT DATE: 08/20/2024
NARRATIVE
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Page 4 of 4.
On 8/29/2022, the Department conducted interviews with 6 residents. 3 Out of the 6 residents do not remember if the facility provides activities. 2 Out of the 6 residents stated the activities are “okay” and provide some activities in the facility. 1 Out of the 6 residents stated the facility does not provide activities to the residents.

Based on facility’s activity calendar, the facility has 4 activities scheduled each day Sunday through Saturday. Each day there is one activity residents to participate in social time, exercise, sensory/brain activities, and snack time.

Based on review of R1’s Appraisal dated 8/9/2021, R1 does not need help in participating in activity program. R1 likes to stay in his/her room watching TV but will join social group if encouraged and invited. R1 is in bed most of the time and enjoys conversing with family and people he/she is familiar with.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Licensee, Irish Ladwig and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
04/29/2022 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20220429161605

FACILITY NAME:HILLSDALE SENIOR LIVINGFACILITY NUMBER:
435202822
ADMINISTRATOR:LADWIG, JUSTINFACILITY TYPE:
740
ADDRESS:1538 HILLSDALE AVE.TELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: DATE:
08/20/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Licensee, Irish LadwigTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medications not given per doctor’s orders.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Licensee, Irish Ladwig and stated the purpose of the visit.

On 4/29/2022, the Department received a complaint with the above allegation. On 5/6/2022, the Department conducted the initial investigation. On 8/29/2022, the Department continued their investigation.

It was alleged that staff do not spend the time to ensure R1 is administered the medication since R1 is difficult and always says no to taking the medication.

Continuation on LIC 9099-C, Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20220429161605
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: HILLSDALE SENIOR LIVING
FACILITY NUMBER: 435202822
VISIT DATE: 08/20/2024
NARRATIVE
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Page 2 of 2.
Based on review of resident (R1)’s medication Administration Record (MAR) for the month of April 2022, 11 out of 11 medications was administered as instructed by physician’s order.

On 5/6/2022, the Department interviewed Administrator (ADM), Licensee and staff S1. 3 Out of 3 staff stated the medications are usually administered after breakfast and after dinner. ADM stated everything is documented, referring to the MARs (Medication Administration Record). ADM stated the facility always provides medications to the residents.

On 8/28/2022, the Department interviewed S2. S2 stated R1 would spit out or throw away the medications and R1’s physician was aware. S2 stated the staff would attempt to administer the medications multiple times before they asked R1’s family members to help administer medications. S2 stated if R1’s family members were visiting, then they would request to administer R1’s medication.

During today’s visit, the Department interviewed 3 staff (S3-S5) and 2 residents (R2-R3). 1 Out of 3 staff were working at the time of the initial complaint investigation. Staff S5 stated resident R1 would refuse to take medications after staff would attempt to administer medications on schedule. S5 stated resident’s family was aware of resident’s refusal to take medications and resident would refuse medications administered by resident’s family as well. 2 Out of 2 residents were at present at the facility at the time of the initial complaint investigation. R2 and R3 stated the staff administer the medications on time and there are not issues of administering the medications on time.

The Department has completed the investigation of the above allegation. Based on interviews conducted and record reviews, 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.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Licensee, Irish Ladwig and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6