435202874-12-15-2024-26-AS-KHOS-DC2RSL-20241217121656

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 12/15/2024
Date Signed: 12/15/2024 05:56:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/24/2023 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20231024163756

FACILITY NAME:	MORNINGSTAR MEMORY CARE AT SAN TOMAS		FACILITY NUMBER:	435202874
ADMINISTRATOR:	GASGONIA, MARK T.		FACILITY TYPE:	740
ADDRESS:	3930 WILLIAMS RD		TELEPHONE:	(669) 201-2015
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	82	CENSUS: 30	DATE:	12/15/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jennifer DeLeon		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident was covered in feces on hands and clothes due to staff neglect.

Resident sustained a laceration on body but staff is unable to provide details of the injury.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 12/15/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the weekend manager on duty, Jennifer DeLeon, who also held the role as the Memory Care Coordinator (Reflections Coordinator) at this time.
A brief interview was conducted with the facility representative Jennifer DeLeon at this time.
Current census was 30 residents.
The purpose of this visit was to inform this facility, and its representative Jennifer DeLeon, that an ongoing investigation has been completed and the following findings were being delivered at this time.
Based on interviews conducted during the course of this investigation, it was learned that this facility was licensed to accept and retain a total of 82 residents. It was learned that this facility accepted and retained residents diagnosed with varying levels of cognitive issues. It was learned that facility residents occupied both the first and second floors at this time.
It was observed that there was an elevator that was used to access the second floor from the lobby. It was learned that there was one central entry/exit point leading out from the lobby area.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2024

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-20231024163756

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: MORNINGSTAR MEMORY CARE AT SAN TOMAS	FACILITY NUMBER: 435202874
	VISIT DATE: 12/15/2024

NARRATIVE

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Based on interviews conducted, it was learned that R1 was involved in an incident around July of 2023. It was learned that R1 was having an episode of aggression and behaviors related to R1's cognitive issues. It was learned that R1 did not want to cooperate with staff who were trying to change R1 since R1 was incontinent of bowel and bladder requiring R1 to wear depends.
It was learned that R1 became even more agitated and started to use R1's hands, arms, and head to hit the floor. It was learned that it was from these actions performed by R1 which led to the abrasions and lacerations on R1's arms and hands.
It was learned that facility staff called for assistance when it was discovered that R1 was starting to escalate in R1's agitative state and other facility staff members were available to respond and render assistance.
It was learned that R1 was subsequently seen by a responding ambulance before being sent out to the local hospital for further evaluation.
Based on interviews, it was learned that aside from this incident involving R1 being aggressive and non compliant with changing R1's depends, it was learned that facility staff were available to assist if residents needed any assistance. It was learned that there weren't any other incidents related to the one involving R1 and staff having to intervene.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2024

LIC9099 (FAS) - (06/04)

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