435202854-7-9-2024-26-AS-RMAO-D79KAS-20240717074422

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202854
Report Date: 05/10/2024
Date Signed: 07/09/2024 04:32:32 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
10/02/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20231002142714

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:	03:26 PM
MET WITH:	Azarel James Equing, HM		TIME COMPLETED:	03:57 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not seek medical attention for resident with lice.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced invetigation visit to deliver the amended investigation finding report and met with House Manager (HM) Azarel James Equing.

On 10/02/2023, the Department received a complaint with the allegation that the facility staff did not seek medical attention for resident with lice.

On 10/12/2023, the Department conducted an initial investigation visit.

LPA interviewed Licensee, Administrator, 2 staff and 2 residents. LPA toured the facility and checked the 2 residents with staff. LPA request the resident physician report and Apprsial/Need and service plan.

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-20231002142714

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facility staff did not seek medical attention for resident with lice:
On 10/02/2023, LPA interviewed resident R1's family (FM). FM stated he/she went to the facility to visit R1 every week. FM stated he/she did not know R1 had lice. FM stated the facility did not notify him/her that R1 had lice. FM stated R1 moved out from the facility on 9/23/2023 and moved to another facility. FM stated on 9/25/2023 he/she received a phone call from the new facility that R1 had lice and it took 7 days to develop to the current condition of lice.

On 10/12/2023, LPA interviewed 2 staff (S1, S2). S1 and S2 stated they did not know R1 had lice. Both stated residents have two showers per week and some residents have bed bath every day if the resident cannot take shower. Both stated the facility staff clean resident bedrooms every day and residents have laundry every day with or without mix of residents' clothes. Both stated the facility cleans resident Iinens 1-2 times per week. Both stated resident R1 moved out from the facility because R1's needed higher level of care.

LPA interviewed Licensee (LCN). LCN stated R1 moved out from the facility because he/she needed higher level of care. LCN stated he/she received a phone call from R1's family that R1 had lice after R1 moved out from the facility two days after. LCN stated after he/she received the notice, he/she spoke to the facility staff and residents. LCN denied the facility had lice. LCN stated R1 went to day program, R1 might get lice from being outside in the community.

LPA toured the facility including the common area, bathrooms and 6 resident bedrooms. LPA did not observe the sign of lice on residents.

LPA interviewed Administrator (ADM). ADM stated the residents have 2 showers per week and as needed, have laundry every day and the facility changes resident's linens every week. ADM stated he/she did not receive any report from staff that R1 having lice.

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: 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: 2 of 3

Control Number 26-AS-20231002142714

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 6/14/2024, LPA conducted a collateral visit at a licensed facility where R1 is currently residing to interview R1. R1 was unable to communicate due to neurocognitive disorders. LPA interviewed a staff S3. S3 stated he/she went to R1's day program to conduct a pre-assessment a week prior to 9/23/2023, the day R1 moved in to the new facility. S3 stated he/she did not find R1 had lice during the pre-assessment..

LPA interviewed 4 staff. 4 out of 4 staff stated R1 moved in the facility on 9/23/2023, and the facility staff found R1 had lice on 9/25/2023. LPA interviewed a staff S4. S4 stated the facility staff found R1 had lice on 9/25/2023, and notified R1's day program. S4 stated R1's day program staff stated that they did not find R1 had lice and the day program did not have any one with lice.

Reviewed R1's resident notes, on 9/25/23, staff found R1 scratching head and lice noted in multiple areas of the head. The facility shampooed R1, and gave shower to R1.

Based on the observation, records reviewed, and interviews, there was no lice found before 9/25/2023. ADM and LNS denied R1 had lice before 9/23/2023, R1's day program also denied R1 had lice before 9/23/2023. R1 moved to the new residency facility on 9/23/2023. There is no evidence to indicate that facility staff did not seek medical attention for resident with lice.

The Department has investigated the above allegation. Based on interviews and observation, the department has found the above allegations 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 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 HM. This report was provided to HM for signature. A copy of the report was provided to HM.

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