435202874-8-27-2025-26-AS-CKAI-DQ4T8E-20260107133011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 08/27/2025
Date Signed: 08/27/2025 11:11:46 AM

Substantiated

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
09/23/2024 and conducted by Evaluator Marcela Yanez

COMPLAINT CONTROL NUMBER: 26-AS-20240923130821

FACILITY NAME:	MORNINGSTAR MEMORY CARE AT SAN TOMAS		FACILITY NUMBER:	435202874
ADMINISTRATOR:	PADILLA SANCHEZ, KENIA		FACILITY TYPE:	740
ADDRESS:	3930 WILLIAMS RD		TELEPHONE:	(669) 201-2015
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	82	CENSUS: 28	DATE:	08/27/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Jessica Pryor, Regional Operations Specialist		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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Staff did not seek timely medical care for resident in care
Staff did not attend to resident in care in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marcela Yanez arrived unannounced to deliver the finding for the above allegations and met with Jessica Pryor, Regional Operations Specialist (ROS).

On 09/23/24, the Department received the complaint. On 09/26/24, the initial complaint investigation was conducted.

The following documents were obtained for this investigation to include the resident roster, staff schedule, 3 resident’s physician’s report, care plan, progress notes, face sheet, centrally stored medication record, medication administration record, resident (R1)’s medical records, and police report.

It was alleged that the staff did not seek timely medical care and did not attend to resident (R1) care in a timely manner when R1 had a fall on 08/05/24.
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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025

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-20240923130821

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: MORNINGSTAR MEMORY CARE AT SAN TOMAS	FACILITY NUMBER: 435202874
	VISIT DATE: 08/27/2025

NARRATIVE

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Based on interview with reporting party (RP). RP stated that R1 fell in the bathroom on 08/05/24 at approximately 0400 hrs. and screamed for help for 3 hours until someone (a facility staff) found R1 at 0730 hrs. and called 911.

Based on the investigation, R1 sustained an unwitnessed fall and was found by facility staff at approximately 0700 hours. R1 was admitted to the hospital by ambulance at approximately 0740 hours.

On 08/06/24, R1 was discharged back to the facility with a diagnosis of an acute brain bleed and was placed on hospice care on 08/05/24.

The facility is equipped with a fall monitoring system set up in each resident’s room in the facility, however, there were no notes indicating the monitoring system caught R1’s fall on 08/05/24.

Based on interviews with 2 witnesses (W1 and W2), W1 reported that he/she received a phone call from the facility staff at approximately 0730 hours on 08/05/24. Staff reported to W1 that R1 fell and was sent to the hospital.

W2 stated, upon notification of R1s fall, they watched a video recording of R1’s room. The video recording was from a personal camera installed in R1s room by W1 and W2 and facility granted permission for the camera. The purpose was to remotely monitor and keep an eye on R1. The camera captured movement and sound made by R1 but there was no visual captured from the bathroom.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20240923130821

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: MORNINGSTAR MEMORY CARE AT SAN TOMAS	FACILITY NUMBER: 435202874
	VISIT DATE: 08/27/2025

NARRATIVE

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W2 stated the following series of events.The camera detected the motion caused by R1 and recorded R1 getting out of bed at approximately 0400 to 0430 hours and entering the bathroom. W2 heard when R1 fell in the bathroom. R1 fell at approximately 0400 hours, afterwards can be heard screaming for help for two to three and a half hours before a staff came and assisted R1 at 0730 hours. There was no visual capturing R1s fall in the bathroom but could be heard in the background screaming for help.

Based on interviews with 4 staff (S1 to S4). S1 stated that on 08/05/24, his/her shift started at approximately 0600 hours and was present. When S1 was asked how three hours could have passed between the time that R1 fell and when R1 was found by facility staff, S1 stated that it was because “someone was not caring for R1.”

S2 stated, on 08/05/24 a caregiver (name unknown) reported to S2 that R1 fell and was not assisted for three to four hours. S2 stated one caregiver and one med tech at night are scheduled to assist all residents. S2 stated that it was possible that R1 had fallen and waited three to four hours because a care giver may not check on residents often enough.

S3 stated, on 08/05/24, his/her shift started at approximately 0630 hrs. S3 was alerted by care staff that R1 had fallen. S3 entered R1s bathroom but does not know how long R1 was on the floor waiting for staff assistance because no one told him/her. S3 stated safety checks are supposed to be conducted every one to two hours at night, however, checks are not documented.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20240923130821

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: MORNINGSTAR MEMORY CARE AT SAN TOMAS	FACILITY NUMBER: 435202874
	VISIT DATE: 08/27/2025

NARRATIVE

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S4 stated R1 was under hospice care. (note: Hospice Care for R1 was initiated after the incident of 08/05/24). S4 stated facility will call hospice to assess R1 before calling 911. S4 stated the facility is equipped with a system called Safely You, which monitors residents’ rooms and alerts facility staff when a fall is detected. S4 was asked how R1 fell on 08/05/24, S4 stated he/she has no recollection of the incident. When asked the length of time R1 had to wait for staff assistance, S4 stated that it was possible that R1 fell and left unattended for three hours because there could have been an emergency involving another resident that would have caused facility staff to not check on R1 for three hours.

Based on review of R1s medical record and facility observation notes, R1 is a fall risk and has sustained multiple unwitnessed falls and R1 requires increased supervision and assistance, R1 is diagnosed with dementia and has a high fall risk. R1 has 30 documented witnessed and unwitnessed falls between 05/25/24 and 09/24/24. A majority of the falls were “witnessed” by the facility’s monitoring system, however on 08/05/24, R1 sustained an unwitnessed fall and no time stamp to indicate R1s fall. R1s care plan includes daily checks from 10:30 a.m. to 9:00 p.m. 4x, from 11:00 p.m. to 4:00 a.m. 3x and from 7:00 a.m. to 8:30 p.m. 4x. No documentation if wellness check were conducted.

Based on observations, interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Citations are issued based on the California Code of Regulations (CCR) Title 22, Division 6, Chapter 8 for Additional Personal Rights of Residents in Privately Operated Facilities and Incidental Medical and Dental Care are cited on the attached LIC 9099D.

An exit interview was conducted with Jessica Pryor Regional Operations Specialist, a copy of the report and appeals rights were provided

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20240923130821

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: MORNINGSTAR MEMORY CARE AT SAN TOMAS	FACILITY NUMBER: 435202874
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/28/2025 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465(g) Incidental Medical and Dental Care: (g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including…apparent life-threatening medical crisis…This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The ROS stated that the facility will conduct In-Service training with staff on wellness checks and will provide proof of training by POC due date 08/28/25
	8 9 10 11 12 13 14	Based on interview and record review, facility staff did not seek timely medical care for R1. On 08/05/24 R1s were recorded calling for help from 0400 to 0730 hrs. Staff were recorded coming into the R1s room at 0730 hrs. and 911 was called. S3 stated he/she was alerted	8 9 10 11 12 13 14	*cont'd: by staff when his/her shift started at approximately 0630 hrs. S4 stated R1 probably waited for four hours to get help because staff is probably attending to another resident emergency need. Which pose/poses an immediate health, safety and personal-rights risk to person in care
Type A 08/28/2025 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities…shall have all the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff… This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The ROS stated that the facillity will conduct In-Service training for staff to ensure residents rights are protected by POC due date 08/28/25
	8 9 10 11 12 13 14	Based on interview staff did not provide care to R1 in a timely manner. On 08/05/24, R1 was recorded screaming for help from 0400 to 0730 hrs. S1 stated R1 waited for hours because “someone is not caring for R1.” S2 stated R1 was possibly waiting for hours to be helped	8 9 10 11 12 13 14	*cont'd :because there are 2 staff for all residents at the time of the incident. S3 stated he/she was alerted by staff when S3 arrived at 0630 hrs. that R1 had fallen in the bathroom. Which pose/poses an immediate health, safety and personal risk to person in care.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025

LIC9099 (FAS) - (06/04)

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