435202832-9-21-2023-26-AS-KHOS-CYEQ6Y-20231211105420

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202832
Report Date: 09/14/2023
Date Signed: 09/21/2023 10:41:42 AM

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
09/05/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230905140701

FACILITY NAME:	PENINSULA SENIOR LIVING MAGNOLIA LLC		FACILITY NUMBER:	435202832
ADMINISTRATOR:	VERMA, SUNIL		FACILITY TYPE:	740
ADDRESS:	176 S BERNARDO AVE		TELEPHONE:	(408) 807-1984
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94086
CAPACITY:	30	CENSUS:	DATE:	09/14/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Neeru Verma		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff abandoned resident

INVESTIGATION FINDINGS:

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THIS IS AN AMENDED REPORT FROM COMPLAINT VISIT ON 09/14/2023. On 09/21/2023 Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the amended complaint report. On 09/14/2023, LPA arrived to the facility unannounced open the initial complaint investigation. LPA met with Administrator, Neeru Verma.

On 09/05/2023, the Department received a complaint alleging a resident was abandoned at the hospital. On 09/14/2023, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1)’s admission agreement, physician’s report, service plan, identification and emergency information, resident assessment, replacement appraisal information, official invoice, notes and observations, medical record, and text message exchanges. SEE LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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-20230905140701

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: PENINSULA SENIOR LIVING MAGNOLIA LLC	FACILITY NUMBER: 435202832
	VISIT DATE: 09/14/2023

NARRATIVE

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On 09/15/2023, 1 witness (W1) was interviewed. Based on interview, on 09/04/2023 R1 was ready to be discharged back to the facility from the hospital. The facility staff was informed. On 09/05/2023, the hospital contacted the facility again regarding R1’s discharge, but the Administrator requested to conduct an assessment prior to R1 coming back to the facility. On 09/06/2023, the Administrator arrived to the hospital to conduct the assessment. On 09/07/2023, resident was discharged with family. R1 was left at the hospital from 09/04/2023 – 09/07/2023.

On 09/14/2023, 2 staff members were interviewed. Based on interview, on 09/04/2023, resident (R1) was transported to the hospital due an unwitnessed fall. Prior to R1’s transfer to the hospital, facility staff was observing behaviors that were of concern to R1’s health and safety, which were documented in R1’s file. S2 states on 09/05/2023, the facility was informed R1 was ready to be discharged from the hospital. On 09/06/2023, staff (S2) went to the hospital to physically assess R1’s condition. S2 stated that based on assessment, R1 was very weak and verbally stated multiple times that he/she did not feel good. S2 stated to express the concern to the hospital social worker and stated it was not safe for R1 to return to the facility. S2 requested the hospital to further evaluate and monitor R1’s mental condition prior to returning to the facility. S2 stated concern of R1’s health and safety after discharge, due to behaviors R1 exhibits at the facility. The facility staff requested for an evaluation from the hospital to better understand R1’s condition, to better meet R1’s needs. S2 states she was not available to assess R1 at the hospital right away due emergencies at S2's other care facility. 2 out of 2 staff stated the facility did not prohibit R1 from returning to the facility.

On 09/14/2023, 2 witnesses were interviewed. Based on interview, R1 did not return to the facility after discharge due to financial concerns and R1's behaviors. W2 stated the facility wanted R1’s mental condition to be evaluated but R1 refused to be evaluated. W3 stated there was no physical or verbal discussion regarding the refusal of accepting R1 back to the facility after discharge from the hospital.

The review of records show the facility observed unusual behaviors from R1 from 05/18/2023 – 09/04/2023.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Neeru Verma and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC9099 (FAS) - (06/04)

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