435202874-12-15-2024-26-AS-KHOS-DC2S49-20241217123223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 12/15/2024
Date Signed: 12/15/2024 06:11:30 PM

Substantiated

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
11/16/2023 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20231116110403

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:	10:30 AM
MET WITH:	Jennifer DeLeon		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Neglect/Lack of supervision by staff to a resident who assaulted another resident.

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.

Substantiated

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)

Page: 1 of 4

Control Number 26-AS-20231116110403

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 during the course of this investigation, it was learned that R1 was very aggressive and often prone to physical confrontations with facility staff, residents, or other third party members who were present at that time.
It was learned that facility residents were constantly in fear of R1 and had to tiptoe around R1 so as not to trigger any aggressive responses from R1.
It was learned that facility staff were also working their shifts in fear of R1 and were always on high alert since they were well aware of R1's explosive behaviors and outbursts.
It was learned that R1's behaviors were easily triggered and facility staff and visiting family members were unaware of what these triggers were so they had to always proceed with caution around R1 so as to avoid any physical confrontations.
It was learned that R1 was in need of a one to one care situation since R1's behaviors and cognitive issues needed to be addressed with more direct supervision and redirection. It was learned that this issue of more direct supervision was not addressed until later on after several incidents had already taken place.
It was learned that R1 was involved in several incidents involving other facility residents, staff members, and other third party members.
It was learned that on one incident R1 was verbally abusive and grabbed hold of another resident and attempted to throw them to the ground.
Another incident involved R1 taking a swing at a facility staff person causing harm and inflicting collateral damage to another resident who was just nearby.
It was learned that R1 had gotten agitated and heated when attempts were made to redirect R1 to where it was learned that R1 picked up a cup of coffee and threw it into the face of a third party member. In addition, the splash from the coffee being thrown also ended up on another resident who was merely nearby.
Incidents such as grabbing a residents eyeglass wear and throwing it for no apparent reason was also learned during this investigation involving R1.
It was learned that later on, after all of these incidents and reported events to this facility were made, R1 did finally receive a direct one on one caregiver and was eventually moved out of the second floor down to the first floor.
It was learned that R1 was kept on the first floor for a majority of the day along with R1's one on one caregiver and was brought back up to the second floor where R1 was then allowed to enter R1's bedroom to sleep at night.

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)

Page: 2 of 4

Control Number 26-AS-20231116110403

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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As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated representative 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)

Page: 3 of 4

Control Number 26-AS-20231116110403

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/16/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section	1 2 3 4 5 6 7	The facility designated representative stated that the personnel requirements and scheduling will be updated to show that the proper level of staffing is being maintained at all times. A statement of correction, along with a copy of the most current staffing schedule for 24 hours/7 days a week
	8 9 10 11 12 13 14	87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This facility was found to be deficient as evidenced by a review of the facility forms and documents revealing that a resident required more one on one care and supervision, with redirection, which posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.	8 9 10 11 12 13 14	coverage, will be completed and submitted into CCL by the due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2024

LIC9099 (FAS) - (06/04)

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