435202841-11-15-2024-26-AS-KHOS-DC2NPE-20241217093812

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202841
Report Date: 11/15/2024
Date Signed: 11/15/2024 12:12:45 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
08/08/2022 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 26-AS-20220808082916

FACILITY NAME:	LIFE SERVICES ALTERNATIVES HATIKVAH HOUSE		FACILITY NUMBER:	435202841
ADMINISTRATOR:	JUSTIN WILLIAMS		FACILITY TYPE:	735
ADDRESS:	577 NORTH CENTRAL AVENUE		TELEPHONE:	(408) 727-3493
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	6	CENSUS: 6	DATE:	11/15/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Justin William		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility does not meet resident's incontinence needs
Staff speaks inappropriately to resident
Staff did not provide resident with first aid
Staff did not inform appropriate parties regarding resident's change in condition
Staff do not assist resident with grooming
Resident is sleeping on the floor

INVESTIGATION FINDINGS:

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On 11/15/2024, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Staff Development Coordinator, Justin Williams and LPA explained the purpose of the visit.

Regarding the allegation of facility does not meet resident's incontinence needs, reporting party (RP) sates that resident R1 sleeps in urine and that R1s diapers are always wet.

LPA was able to interview the administrator (ADM1) during this time and it was stated that R1 was always looked after since R1 is the only one left in the facility while the others are in day programs or working. Constant checkups are being done with the resident. There are also pads placed on the bed for R1. Staff are also aware of R1s condition of being incontinent. Another staff member (S1) stated that he/she assists R1 with cleaning and changing the diaper as needed on an observational basis. S1 also stated that he/she will check R1s diaper for wetness approximately 3 times per shift.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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 3

Control Number 26-AS-20220808082916

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: LIFE SERVICES ALTERNATIVES HATIKVAH HOUSE	FACILITY NUMBER: 435202841
	VISIT DATE: 11/15/2024

NARRATIVE

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Regarding the allegation of staff speaks inappropriately to resident, RP stated that staff (RP doesn't know names) always screams at R1 "when staff wants the resident to comply”.

According to a staff member S2, there’s a staff who is an excellent staff member (S3), but sometimes speaks loudly, doesn't yell, but it comes across as yelling, but just speaks very loudly. S3 is never saying anything demeaning or punitive or anything, S3 is one of the best caretakers, he/she just happens to speak loudly. Residents have never expressed discomfort from that. S1 also stated that he/she has never observed staff harm residents or speak to them in an inappropriate manner.

Based on observations, LPA Donato saw residents are comfortable with staff at the facility. Residents are always talking to staff when they need anything.

Regarding the allegation of staff did not provide resident with first aid, RP stated that R1 had an issue with one of his/her knees, and R1 needed ice placed on his/her knee. However, instead of assisting R1, staff stated "things have to be written out."

S1 mentioned that when asked if a doctor's order is needed to apply ice to a resident's wound daily, ADM1 stated that they would. Facility needs to get doctors’ orders.

Regarding the allegation of Staff did not inform appropriate parties regarding resident's change in condition, RP states that R1 was given new medication, and that the resident became withdrawn. However, staff did report the resident's condition to the conservator, nor consult the conservator prior to the resident being prescribed new medication.

According to S1, in the beginning R1 had an incontinence medication that the doctor wanted to stop. R1 was seeing things that weren't really happening, when R1 told the doctor that, the doctor stopped the incontinence medication because they cause confusion. The family came to ADM1 and asked why a medication (M1) was at 50mg instead of 25mg as per usual. The family wanted M1 be reduced to 25mg, which began the start of the confusion phase. The doctor was surprised that the family was not approving the increase in dose of medication. ADM1 stated that they were not sure when the medication dosage was increased and if the family was notified of the change. ADM1 also shared that they only follow what medication the doctor prescribes.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20220808082916

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: LIFE SERVICES ALTERNATIVES HATIKVAH HOUSE	FACILITY NUMBER: 435202841
	VISIT DATE: 11/15/2024

NARRATIVE

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Based on records review, on 8/03/2022, R1 had a doctors appointment. During this appointment It was brought up the potential need for medication change and to address the leg pain. The doctor prescribed an up in dosage for M1. R1 was accompanied by family members during this visit.

Regarding the allegation of staff do not assist resident with grooming, RP states that staff do not keep up R1s hygiene, and that R1 is filthy and has long nails.

Based on records review, according to R1s individual program plan (IPP), R1 s independent in some personal care skills. According to S1s interview, S1 stated that he/she sometimes assists R1 with showering through verbal prompting. When asked whether or not S1 assists R1 with general grooming such as combing hair or clipping nails, S1 stated that he/she does not assist with those tasks and that R1 typically does them on her own.

Regarding the allegation that resident is sleeping on the floor, RP states that although the conservator bought R1 a new bed, the resident was sleeping on the floor.

Based on the staff interviews, S1 mentioned that they have never observed any residents sleeping on the floor or with disassembled beds. ADM1 also stated that they have not seen any residents sleep on the floor, only on the sofa by the family room. Staff also does hourly checks at night when residents are asleep and there has been no report of residents sleeping on the floor.

Based on interviews, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

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