435202854-7-9-2024-26-AS-RMAO-D7AKEE-20240718075011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202854
Report Date: 05/10/2024
Date Signed: 07/09/2024 04:31:02 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
01/16/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20240116100529

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:	05/10/2024
		UNANNOUNCED	TIME BEGAN:	03:55 PM
MET WITH:	Justin Ladwig		TIME COMPLETED:	04:26 PM

ALLEGATION(S):

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Staff are not addressing an insect infestation at the facility.
Staff are not following proper food services sanitation practices.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the amended investigation report and met with Administrator (ADM) Justin Ladwig.

On 01/16/2024, the Department received a complaint with the above allegations.

On 01/26/2024, an initial investigation visit was conducted. LPA interviewed the House Manager, 2 staff, 5 residents, a private caregiver, and a nurse.

LPA obtained LIC500 personnel report, the facility cleaning schedule and the facility infection control plan/protocol.

Continue on LIC9099-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: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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-20240116100529

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: 05/10/2024

NARRATIVE

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Staff are not addressing an insect infestation at the facility:
On 1/26/2024, at 1:00PM, LPA arrived at the facility. Staff S1 opened the door for LPA. LPA toured the kitchen and the facility with S1. LPA observed dishes in the kitchen sink. S1 stated he/she and another staff just finished helping residents for lunch and was washing dishes when LPA arrived. LPA did not observe insects, cockroaches, ants on the kitchen counter or on the kitchen floor. LPA did not observe any "insect trap" on the kitchen counter or on the floor.

LPA toured the dining room, living room, reading rooms, laundry room, resident rooms and restrooms. LPA did not observe insects, cockroaches, ants or any "insect traps".

LPA interviewed house manager (HM). HM stated the facility had cockroaches around in the middle of last year. HM stated the facility conducted treatment for that. HM stated the facility does not have insect, cockroaches, or ants after the treatment. HM stated he/she did not see insects, cockroaches, or ants recently. HM stated facility staff clean the facility in the morning and in the evening every day. HM stated the facility staff clean the kitchen before and after each meal.

LPA interviewed 2 staff (S1, S2). both staff stated the facility staff clean the facility in the morning and evening every day, and the staff clean the kitchen before and after the meals. Both stated they did not see insects, cockroaches or ants in the facility recently.

LPA interviewed 5 residents. 5 out of 5 residents stated the facility is clean. 3 out of 5 residents stated they did not see insects, cockroaches, or ants in the facility.

LPA interviewed a private caregiver (PC). PC stated the facility is clean and the food is good. PC stated he/she does not see the facility has any problem. LPA interviewed a nurse at the facility. The nurse stated the facility everything is good and clean. The nurse stated the facility is the top level of the facilities he/she ever visited.

Based on the interviews with staff and residents and observation, no evidence to indicate that staff are not addressing an insect infestation at the facility.

Continue on LIC9099-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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240116100529

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: 05/10/2024

NARRATIVE

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Staff are not following proper food services sanitation practices:
On 01/26/2024, LPA toured the facility kitchen. LPA did not observe insects, cockroaches, ants, or "insect traps" on the kitchen counter. LPA interviewed 3 staff. 3 out of 3 staff stated they did not see insects, cockroaches, or ants in the facility. 3 out of 3 staff stated the facility staff clean the kitchen before to cook meals and clean the kitchen after the meals. LPA interviewed a facility cook, he/she stated he/she did not put "insect trap" on the kitchen counter.

LPA interviewed a resident R1 who stated the facility staff prepare their meals in good sanitation practices. LPA interviewed 5 residents. 5 out 5 residents stated the facility food was good. 5 out of 5 residents stated the facility has no insects or bugs and the kitchen is clean.

LPA interviewed a private caregiver on site and a home care nurse on site in the facility. Both stated the facility food is good. Both stated they did not find any issue of the procedures of the facility food processing for the meals.

On 6/14/2024, LPA interviewed 4 staff. 4 out of 4 stated they received the training for food preparation and food processing. 2 out of 4 staff addressed the procedures of food preparation and food processing for cooking the meals. LPA obtained and reviewed the facility Food Safety Best Practices documents. ADM stated the Food Safety Best Practice document is the guideline for staff to follow.

Based on the observation, records reviewed and interviews with staff and residents, there is no evidence to indicate that the facility staff are not following proper food services sanitation practice.

The Department has investigated the above allegations. Based on interviews and observation, the department has found the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid, there is not a preponderance of evidence to show the alleged violations did or did not occur.

No citation noted today per California Code of Regulations, Title 22. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.

Page 3 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3