435202856-8-15-2023-26-AS-RMAO-CUYJTD-20230823071946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202856
Report Date: 08/15/2023
Date Signed: 08/15/2023 12:29:09 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
03/06/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230306101131

FACILITY NAME:	BELMONT VILLAGE LOS GATOS		FACILITY NUMBER:	435202856
ADMINISTRATOR:	MARTINEZ, RADHIKA		FACILITY TYPE:	740
ADDRESS:	5121 UNION AVENUE		TELEPHONE:	(408) 569-3333
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	175	CENSUS:	DATE:	08/15/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Executive Director Radhika Martinez		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Staff handled resident in a rough manner

Staff prohibit resident from entering the facility dining room

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPA met with Executive Director Radhika Martinez.

On 03/06/2023 the Department received a complaint alleging facility staff prohibits resident R1 from entering the facility dining room. It has also been alleged that the facility staff handled R1 in a rough manner on 2/19/2023 by dragging him/her out of the dining room. It was also alleged that S1 tackled R1 to the floor on 2/25/2023.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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-20230306101131

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: BELMONT VILLAGE LOS GATOS	FACILITY NUMBER: 435202856
	VISIT DATE: 08/15/2023

NARRATIVE

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On 03/14/2023, LPA Steve Chang interviewed staff (S1). S1 stated dinning is separated based on two groups. S1 stated group 1 are residents who can eat by themselves while group 2 are residents that may require staff to supervise or assist residents. S1 stated R1 was in group 2. S1 stated on 02/25/2023, R1 attempted to enter the dining area but group 1 was still dining. S1 stated he/she attempted to redirect R1 to sit down but somehow R1 was on the floor. S1 stated he/she was unsure if R1 just sat down or slid down on the floor.

LPA Chang interviewed staff (S2 & S3). S2 stated, regarding the alleged tackling, he/she did not see S1 push R1. S2 & S3 stated paramedics came to the facility, assessed R1 and deemed him/her stable and was not sent to the hospital. S2 stated R1 was in Group 2, but sometimes R1 did not want to wait at the activity room to wait for Group 1 residents to finish.

LPA Chang interviewed resident (R1). LPA asked R1 if anyone pushed or hit R1 recently. R1 stated no. LPA asked R1 if he/she fell recently. R1 answered no.

LPA Chang interviewed Senior Executive Director (ED) Radhika Martinez. ED stated memory care unit residents have 2 groups for the dining room. ED stated Group 1 will finish meals first, and Group 2 members wait for outside first at the activity room. ED stated R1 was never prohibited from entering the dining room. ED stated the dining room cannot hold all the member care unit residents at same time, because some residents do not want to sit with other residents. ED stated the police came to the facility on 02/25/2023 because if a resident hit there head it company police to request paramedics.

On 8/15/2023, LPA Manuel Monter interviewed Staff S1, S2, S3, S4, and ED. S1-S4 and ED stated R1 was never dragged by the staff on 2/19/2023. S1-S4 and ED stated this did not happen.

Based on a review of Belmont Village Variance report dated 02/25/2023, paramedics assessed R1 and deemed R1 stable. R1 was not taken to the hospital.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230306101131

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: BELMONT VILLAGE LOS GATOS	FACILITY NUMBER: 435202856
	VISIT DATE: 08/15/2023

NARRATIVE

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Based on additional information, staff (S5) was interviewed by law enforcement regarding the incident that occurred on 02/25/2023. S5 stated he/she heard R1 screaming and walking towards the open cafeteria door. S5 stated he/she saw S1 running towards the door, towards R1’s location. S5 stated he/she saw S1 lean forward and noted R1 fell. S5 stated he/she did not see S1 put hands on R1 but believed that S1 pushed R1.

Based on the interviews conducted with clients and staff and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited, Exit interview conducted with Executive Director Radhika Martinez and a copy of the report was provided.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC9099 (FAS) - (06/04)

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