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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202856
Report Date: 02/23/2024
Date Signed: 02/24/2024 03:41:34 PM

Substantiated


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
11/30/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20231130121323
FACILITY NAME:BELMONT VILLAGE LOS GATOSFACILITY NUMBER:
435202856
ADMINISTRATOR:MARTINEZ, RADHIKAFACILITY TYPE:
740
ADDRESS:5121 UNION AVENUETELEPHONE:
(408) 569-3333
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:175CENSUS: 110DATE:
02/23/2024
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Jeeteeh GigliottiTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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A resident had untreated open wound from a fall injury due to neglect/lack of supervision.
Facility did not seek timely medical attention for the resident’s wound injury.
Facility did not submit an incident report to licensing agency.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Steve Chang and Mita Partoza conducted an unannounced investigation visit to deliver the investigation findings and met with Director of Resident Care Services (DRCS) Jeeteeh Gigliotti.

On 11/30/2023, the Department received allegations that the facility did not seek timely medical attention and neglected care and supervision of a resident herein referred to as R1.

On 12/08/2023, the Department conducted an initial investigation visit. LPAs requested resident physician report, appraisal needs and service plan, nurse evaluation report, communication log between the facility and doctor, and doctor order.


Continue on LIC9099-C. Page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
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 5
Control Number 26-AS-20231130121323
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: BELMONT VILLAGE LOS GATOS
FACILITY NUMBER: 435202856
VISIT DATE: 02/23/2024
NARRATIVE
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On 11/30/23, the Department received allegations that the facility did not seek timely medical attention and neglected care and supervision for a resident herein referred to as R1. R1 had an untreated wound which was not reported to licensing office.

On 12/08/23, the Department conducted an initial investigation and interviewed staff (S1). S1 stated that R1 had an unwitnessed fall sustaining an injury to the left elbow with a superficial skin tear on 11/21/23.

S1 stated that R1s fall was reported to responsible party (RP) and medical doctor (MD). S1 stated that R1’s wound was not serious, was cleaned and a band aid was applied. Since it was not serious, the facility did not report R1’s wound to licensing.

On 11/27/23, R1’s responsible party moved R1 to another Residential Care Facility for the Elderly (RCFE). It was reported that during R1’s assessment the facility did not inform the prospective facility that R1 sustained a wound on elbow aside from other minor abrasion on his/her knee during an assessment.

Based on review of Nurse’s notes dated 11/21/23, it was noted that R1 reported to the Wellness Nurse at 9AM that he/she fell during the night but does not remember how it happened. R1 sustained a left skin tear on left arm and some redness on left knee. R1s wound was cleaned and treated, and dressing applied. R1’s primary care physician (PCP) was notified on the same day [11/21/23] with a reply date of 11/24/23 which states, “can give Tylenol 500mg every 6 hours … and please wash skin tear clean and put band aid over.”

On 11/28/2023, R1’s wound was reported to his/her PCP. PCP stated the facility staff did not describe the severity of the wound and how bad it was when he/she received a note from the facility On 11/21/23, the note states that R1 had a skin tear on left arm and some redness on the left knee. PCP prescribed R1 some antibiotics and will require the services of a home Health aide to come and assist with the wound care for R1 at his/her new placement.

Based on record review such as R1’s physician’s report dated 5/23/23, R1 has diagnosis of neurocognitive disorder.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20231130121323
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: BELMONT VILLAGE LOS GATOS
FACILITY NUMBER: 435202856
VISIT DATE: 02/23/2024
NARRATIVE
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On 12/05/2023, LPA interviewed R1’s responsible party (referred to as RP). RP stated that on 11/21/23, he/she received a phone call from the facility staff to report that R1 had a fall and PCP was notified who prescribed medication for pain. RP stated there was no mention of R1’s sustaining a wound on the left elbow.

RP became aware of R1’s wound on left elbow a day after R1 was admitted at another facility on 11/28/23 reported by the facility nurse, herein referred to as W1. RP stated that R1 moved out from the facility [Belmont Village] on 11/27/23.

On 12/08/2023, the Department interviewed staff S1. S1 stated R1 did not complain about pain, per their procedure does not require staff to report to licensing if it is not critical or does not require any hospital visit/emergency. Based on interviews, and records reviewed, of incident submitted to the department, a report was not filed with licensing addressing R1s unusual incident (injury/fall) in November 2023.

Based on records review of R1s progress note, no other reports was written after 11/21/2023 that the wound has been addressed.

On 12/09/2023 the Department interviewed witness (W1) that R1 was assessed at Belmont Village prior to R1’s placement on 11/27/23. According to W1, it was mentioned by the wellness director or nurse [at Belmont] that R1 had a fall but no mention of an open wound on R1’s left elbow during assessment. W1 stated that R1’s wound discovered when R1’s moved in day on 11/27/23 which was covered by translucent tape over the wound with yellowish color appeared to be infected and wound dressing has not been changed.

On 12/10/2023, an interview with W1 was conducted. W1 stated that the facility [Belmont] did not allow them to conduct skin assessment.

Based on the Department’s findings, record reviews and interviews, there is sufficient evidence to prove that the allegation of neglect or lack of supervision, not seeking medical attention in a timely manner, and not reporting incident to licensing agency occurred. The preponderance of evidence gathered and analyzed indicated that the allegation is true, therefore, the allegations are substantiated.

Deficiencies are cited based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with DRCS Jeeteeh Gigliotti and a copy of the report and appeals rights were provided.

Page 3 of 3

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20231130121323
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: BELMONT VILLAGE LOS GATOS
FACILITY NUMBER: 435202856
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/24/2024
Section Cited
CCR
87466
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87466 Observation of the Resident The see shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.This requirement is not met as evidenced by:
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Administrator stated to submit a plan of correction by the POC due date to develop a protocol on documentation for residents in care and supervision.
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Based on records reviewed and interviews, no progress notes that was made to document R1s wound condition after 11/21/2023. This posed an immediate health and safety risk to persons in care.
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Request Denied
Type A
02/24/2024
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care. (a) (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement is not met as evidenced by:
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Administrator stated to submit a plan of correction by POC due date to address wound care.
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Based on interviews, and records reviewed, the facility staff did not follow up with R1s PCP after the initial consultation of R1's wound treatment on 11/21/2022. This posed an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20231130121323
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: BELMONT VILLAGE LOS GATOS
FACILITY NUMBER: 435202856
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/01/2024
Section Cited
CCR
87211(1)(D)
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87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency ...(1) A written report shall be submitted to the licensing agency...(D) Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by:
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Administrator stated will submit a plan of correction (POC) on reporting requirements.
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Based on interviews, and records reviewed, of incident submitted to the department, a report was not filed with licensing addressing R1s unusual incident (injury/fall) in November 2023. This posed an potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5