435202862-1-23-2025-26-AS-KHOS-DENJV3-20250311072228

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202862
Report Date: 01/23/2025
Date Signed: 01/23/2025 12:22:53 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
06/09/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230609132651

FACILITY NAME:	HANSELL VILLA		FACILITY NUMBER:	435202862
ADMINISTRATOR:	PAREDES, FREDERIC		FACILITY TYPE:	740
ADDRESS:	5343 HANSELL DRIVE		TELEPHONE:	(408) 802-0215
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 6	DATE:	01/23/2025
		UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Nida Agbayani		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff are not maintaining resident's hygiene
Staff are not turning the resident to prevent pressure wounds
Staff are not dressing the resident
Facility is not providing resident records to resident representative

INVESTIGATION FINDINGS:

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On 1/23/2025 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit at the facility. LPA met with Care Staff Nida Agbayani and explained the purpose of the visit.

Regarding the allegation of staff are not maintaining resident's hygiene, Reporting Party (RP) stated that they have found client (R1) with fecal matter under nails on bed and on clothing. Per RP care home staff reports that client is mean, aggressive, and angry and scratches staff.

LPA Maruffo was able to interview three staff members, according to S1, they always check R1s diapers every time. If we smelled not good, we would need to check. If S1 tried to feed R1, R1 would scratch us and say get out of my room. R1 did not have dirty fingernails. R1 never had feces in his/her fingernails. R1 did not have stains on the bed or sheets and on her clothes. S2 also shared that his/her family (F1) gave R1 a bed bath. No, we would not shower R1 because he/she refused. R1 said no, get out. R1 doesn’t listen to the care giver, only listens F1.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

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-20230609132651

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: HANSELL VILLA	FACILITY NUMBER: 435202862
	VISIT DATE: 01/23/2025

NARRATIVE

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S2 never noticed any dirt or anything underneath R1s fingernails. R1 never scratched his/her butt. R1 never had any poo stains on him/her or bed sheets or on the clothes. S1 and S3 mentioned that the beddings are changed three times a week.

Additionally, LPA Maruffo interviewed four residents. R2 stated that staff assists a little bit. They assist with bathing. They may change the beddings when R2 is out in the kitchen eating. Usually, they clean R2s clothes every day or every two days. They bathe R2 every morning and R2brushes his/her own teeth. R3 shared that the staff showers him/her. R3 is showered two times per week. The staff help R3 brush his/her teeth. They change my diaper out. They change my diaper every other day. R4 mentioned that staff cleans his/her bedding. They clean R4s bedding every day. They throw out the old pads and put the new stuff in. R4 doesn’t know how often they clean the bedsheets. Staff cleans R4s clothes every day. R5 mentioned that someone comes in and does cleaning. Someone comes in at night and changes the bed sheets. R5 has never seen them (bedsheets) dirty or anything. Staff cleans R5s clothes whenever he/she needs it.

Regarding the allegation of staff are not turning the resident to prevent pressure wounds, RP stated that the physical therapist (PT) came out there after Memorial Day and told them they have to reposition R1 every couple hours and not once have they done it.

According to interviews, S1 stated that R1 is required to be turned in bed. S1 would turn R1 every two to three hours around the clock. That was the advice of the administrator. R1 did not have any bed sores. S2 also added that R1 required to be turned every 3 hours. Staff would turn R1 every 3 hours. S3 also shared that R1 is required to be turned. S3 always tell staff to turn the clients every two hours to avoid bed sores. R1 did not get any bed sores.

Based on records review, on the visit notes, visit done by PT on 5/23/2023, it was noted that R1 was confused and resistive, unable to get vital signs due to agitation. Educated caregiver for bed mobility.

Regarding the allegation of staff are not dressing the resident, RP stated that not once have they changed R1s top, R1 has been in the facility for 21 days.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230609132651

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: HANSELL VILLA	FACILITY NUMBER: 435202862
	VISIT DATE: 01/23/2025

NARRATIVE

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Based on the interviews, R2 stated that staff usually has R2 dressed in pants and t shirt. R3 mentioned that the staff do not put pants on him/her. R2 says if he/she has a visitor, they will put pants on R3) R3 nods to confirm what R2 said. R4 mentioned that he/she usually have shirts and pants on. R5 shared that he/she dress himself/herself.

For the staff interviews, S1 mentioned that they change the residents clothing every morning. R3 doesn’t wear pants. R4 has jeans. If R4 wants to go to sleep, he/she tells staff to remove his/her pants. R4 wants to remove his/her pants after lunch because he/she doesn’t like to have them on. S1 also shared that they did not put pants on R1. R1 did not want them. When staff tried to put pants on R1, R1 would shout at staff. R1 only wanted his/her blouse and the diapers. According to S2, they dress the residents. The residents are fully dressed with shirts and pants every day. R3 doesn’t have pants on because it is hot. R3 always covers himself/herself with blanket because it is too hot. R4 takes off his/her pants this afternoon and at 3PM S2 changes the diaper and put back on the pants. S3 added that R1 refused to put his/her pants on. R1 has a long gown on and shirt. R1 said that he/she is not comfortable putting on the pants.

Regarding the allegation of facility is not providing resident records to resident representative, RP stated that he/she signed the paperwork on May 12, 2023 and did not get a copy. On June 1st, RP requested copies of the paperwork from the administrator in person and in text. RP sent another text reminding the administrator to provide copies of the documents. He/she has not responded to the requests.

According to S3,it was mentioned that they no longer have R1's file because it was given to the paramedics when they arrived to pick R1 up and send R1 to respite care. S3 said they will be able to return the file to me. R1s family member never asked me for the records.

Based on records review, LPA Marrufo was able to obtain the files of R1 which was faxed to LPA by the facility. Records obtained were physicians report, admission agreement, needs and services plan, emergency information.

Based on interviews and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Report is reviewed and copy is provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC9099 (FAS) - (06/04)

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