435202854-12-12-2022-26-AS-KHOS-CMKRMC-20221229120833

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202854
Report Date: 12/12/2022
Date Signed: 12/12/2022 04:31:13 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/28/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220228140135

FACILITY NAME:	CAMBRIAN SENIOR LIVING		FACILITY NUMBER:	435202854
ADMINISTRATOR:	LADWIG, JUSTIN		FACILITY TYPE:	740
ADDRESS:	3520 MAY LANE		TELEPHONE:	(408) 914-1147
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	6	CENSUS: 5	DATE:	12/12/2022
		UNANNOUNCED	TIME BEGAN:	01:50 AM
MET WITH:	Irish Ladwig		TIME COMPLETED:	02:30 AM

ALLEGATION(S):

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Resident sliding down recliner chair without staff within immediate proximity/direct supervision.
Facility staff didn't respond within acceptable time period when resident was calling for help.
Resident did not receive refund money within 10 days after moved out from facility.
Facility staff did not administer medication properly.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint Investigation visit to deliver the investigation findings, and met with Administrator (ADM) Irish Ladwig.

On 02/28/2022, the Department received a complaint with above allegations.

On 03/04/2022, LPA Steve Chang conducted an initial 10 day inspection/investigation, and met with ADM. LPA interviewed ADM, and 2 staff (S1, S2). Resident's Physician’s Report, Appraisal/Needs and Service Plan were obtained.

Continued on 9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

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-20220228140135

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CAMBRIAN SENIOR LIVING	FACILITY NUMBER: 435202854
	VISIT DATE: 12/12/2022

NARRATIVE

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Resident sliding down recliner chair without staff within immediate proximity/direct supervision:
Facility staff didn't respond within acceptable time period when resident was calling for help:

On 3/4/2022, LPA interviewed ADM and two staff (S1, S2). S1, S2 and ADM stated that on 2/8/2022, a witness (W1) Observed a resident (R2) slid down in a recliner chair in the living room without staff supervision in the living room.

S1 and S2 R2 was in the living room in his/her recliner chair. Staff left R2, as a usual routine, while assisting residents in the facility. They stated it took them about 5 minutes to assist a resident who required transferring. They stated that R2 slid a little bit in the recliner chair wherein they repositioned R1's posture.

On 3/4/2022, LPA conducted an interview with ADM who stated R1 was assessed by staff and found to have no injuries.

Based on the investigation and interviews conducted, resident was observed sliding from a recliner chair without supervision. The resident did not sustain a fall that result in an injury. staff repositioned resident in his/her recliner chair immediately upon observing resident's body posture.

Resident did not receive refund money within 10 days after moved out from facility:

On 03/4/22, LPA interviewed ADM. ADM stated that a cashier check was issued and sent to R1’s primary address on 2/17/22, on the 7^th day after R1 moved out from the facility.

ADM stated he/she called R1 and left message on 3/7/2022. ADM stated he/she did not get any response from R1. ADM was not sure if the cashier check was lost in the mail. ADM stated he/she cancelled the cashier check on 3/8/2022.

Continued on 9099-C. Page 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220228140135

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CAMBRIAN SENIOR LIVING	FACILITY NUMBER: 435202854
	VISIT DATE: 12/12/2022

NARRATIVE

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ADM stated that he/she issued a personal check to R1. ADM drove to R1's address on file on 3/8/2022. ADM stated he/she was unable to deliver the personal check to R1 due to no one answering the door.

On 3/10/2022, ADM called and left voicemails for R1 and R1's private caregiver (PC) to pick up resident's refund check. On 3/10/2022, ADM contacted placement agency and was informed that R1 has died. ADM was told that R1 does not have family.

Based on the documents reviewed and interviews conducted, the facility issued and sent the refund check on the 7th day after R1 moved out from the facility. The check was not cashed and resident did not come to facility to pick up the refund check. ADM tried to reach R1 and unable to reach resident or resident's family.

Facility staff did not administer medication properly:
On 3/4/2022, LPA interviewed ADM. ADM stated R1's private caregiver (PC) asked facility to provide R1 pain medication every 4 hours. ADM stated R1's pain medication was ordered to be given as needed.

ADM stated R1's hospice nurse confirmed that the facility must follow Doctor's order to use the pain medication as needed. ADM stated R1 stated that he/she took medications as needed prior to adminission. ADM stated Kaiser Hospice confirmed that the medication was administered per MD's order. ADM stated the facility administered the pain medication as needed. On the same day, LPA interviewed S1. S1 stated he/she asked R1 several times if R1 needed pain medication, but R1 always responded no.

Based on the investigation conducted and interviews conducted, the facility followed the doctor's order to administer the pain medication to resident as needed.

The department has investigated the above allegations. Based on the investigation, observations, 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.

No citations noted at today’s complaint investigation visit. Exit interview was conducted with ADM. A copy of this report was provided to ADM.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC9099 (FAS) - (06/04)

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