435202874-7-8-2025-26-AS-KHOS-DJLKE6-20250715074950

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 07/08/2025
Date Signed: 07/08/2025 05:19:08 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
01/27/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20250127135342

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: 24	DATE:	07/08/2025
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Regional Operations Specialist Krystal Jenkins		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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Staff are not implementing proper infection control practices at the facility
Staff did not provide adequate laundry services to residents in care
Staff did not provide good quality foods to residents in care
Residents sustained multiple falls due to insufficient staff at the facility
Staff did not order resident's medication in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Regional Operations Specialist Krystal Jenkins.

On January 27, 2025, the Department received a complaint alleging Staff are not implementing proper infection control practices at the facility / Staff did not provide good quality foods to residents in care. It has also been alleged the food was contaminated.

Page 1 Out of 6.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

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 6

Control Number 26-AS-20250127135342

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: 07/08/2025

NARRATIVE

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On January 31, 2025, LPA Simi Rai interviewed Executive Director (ED) Kenia Padilla. ED stated there was a Norovirus outbreak 2 weeks ago. ED stated the initial case was on 1/13/2025. The visitors were notified with posters at the front and throughout the building. ED stated there were 4 residents with positive Norovirus and everyone went into isolation. ED stated the Maintenance Director maintained a log for sanitization. ED stated she informed the Department of Health Services and they advised her to close the dining room. ED stated each resident would have a 3-drawer cart and each cart would have PPE supplies such as N95/masks, eye safety glasses, shoe covers, gloves, hand scantier, and gowns. ED stated the staff would prepare the meals in the kitchen, place food in individual containers and give each resident their food in their rooms. ED stated she knows the staff were following food service sanitation practices because she was on the floor as well, serving the food to the residents. ED stated last week, they started to bring residents into the dining room which needed assistance with feeding and place them 6 feet apart.

LPA Rai made the following observations during the complaint investigation visit. LPA Rai observed the kitchen area. LPA Rai observed the kitchen prep area, the dishwasher area, pantry and refrigerator/freezer. All areas were clean and clear of dust and debris. LPA Rai observed the laundry room. LPA Rai observed 3 washers, and 2 dryers. One dryer was out of service, but it going to be repaired. LPA Rai observed two resident rooms Room 213 and 103 which stored PPE supplies. LPA Rai observed boxes of gloves, masks, gowns, sanitizing wipes and trash cans with lids.

On July 8, 2025, LPA Manuel Monter interviewed residents R1-R7. R6 and R7 residents interviewed were unable to provide answers to questions LPA's posed. Residents R1-R5 stated they don't know what the facility did when there was an outbreak and have no knowledge.

LPA Manuel Monter and Marcella Tarin interviewed staff S1-S4. All staff interviewed stated the facility follows infection control protocols when there is an outbreak. All staff interviewed stated facility staff wear gloves and dispose of them when they are finished providing care inside a residents bedroom.

LPA interviewed Health Services Director (HSD). HSD stated the facility is following there infection control protocols. HSD stated kitchen staff do not provide care giving services to residents. HSD stated kitchen staff follow infection control protocols. HSD stated when there is an outbreak, the facility will deliver meals to residents apartments and provide disposable dinning wear. Page 2 Out of 6.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20250127135342

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: 07/08/2025

NARRATIVE

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On July 8, 2025, LPA Manuel Monter PPE supplies, which included, but not limited to: gloves, masks, gowns.

Based on a review of facility Receipts, the facility does have documentation showing they have bought PPE in November 2024, December 2024 and January 2025.

The Department reviewed staff training documents from November 2024, December 2024, January 2025 : Falls and fractures, Residents ADL’s, PPE use, Hand Hygiene, Fall prevention, GI Virus/Infection Control & an In-Service food safety and preventing Cross contamination.

Based of facility documentation, the facility had a Sanitation log of common areas. This included Door knobs, chairs, tables, elevators, buttons, floors and restrooms. Furthermore, the log begins in January 6, 2025- January 31, 2025.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Residents sustained multiple falls due to insufficient staff at the facility

On January 27, 2025, the Department received a complaint alleging residents sustained multiple falls due to insufficient staff at the facility

On January 31, 2025, LPA Simi Rai interviewed Executive Director (ED) Kenia Padilla. ED stated some families are confused and they think they provided 1:1 care giving, but they don't. ED stated their staff do not break the fall, the caregivers will support the resident afterwards.

LPA Rai made the following observations: LPA Rai observed 12 residents and 3 staff (1 activity person and 2 agency staff).

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 26-AS-20250127135342

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: 07/08/2025

NARRATIVE

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On July 8, 2025, LPA Manuel Monter interviewed residents R1-R7. Residents R1-R4 stated they have no issues or concerns regarding staffing. Residents R5-R6 stated they don't know about any staffing issues and have no knowledge. Residents R7 was unable to provide LPA with any response to questions posed.

LPA Monter interviewed staff S1-S4. All staff interviewed stated there is no resident in the facility that requires 1:1 staffing. All staff interviewed stated there is sufficient staff to meet the needs of the residents.

LPA Monter interviewed Health Services Director (HSD). HSD stated the facility has sufficient staffing to meet the needs of residents.

On June 23, 2025 and July 8, 2025, LPA toured the facility inside and out. LPA toured the common areas and resident bedrooms. LPA did not observe the facility in disrepair or unclean. While touring the facility LPA did not observe any resident in a soiled or disheveled state.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Staff did not order resident's medication in a timely manner

On January 27, 2025, the Department received a complaint alleging Staff did not order resident's medication in a timely manner

On January 31, 2025, LPA Simi Rai interviewed Executive Director (ED) Kenia Padilla. ED stated the facility staff are responsible for refilling the medication for the residents. They either use Kaiser and/or Pharmerica. ED stated there was one particular family where there was an issue with refilling the medication on time and the Wellness Director can talk more about it. Ed stated the pharmacy is either delaying the delivery of the medication or lying about not delivering the medications at the facility.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20250127135342

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: 07/08/2025

NARRATIVE

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LPA Rai interviewed Wellness Director (WD) Carmen. WD stated they will send the medication order to the pharmacy (Pharmerica) and they let the resident's family and PCP know about the delay. W1 stated they let the doctor know by phone call or fax. W1 stated the issues comes in the place when the resident's medications order is done with refills, and the pharmacy needs to get new orders from the doctor and that causes a delay. W1 stated they have discussed this issue with the pharmacy regional office and their facility's regional office. W1 stated the residents that have issues with refills are R1 and R2.

W1 stated if there are 7-10 pills left in the medication, they will notify the pharmacy for refill. But the pharmacy will delay the delivery. W1 stated the pharmacy will say the medication is en-route to be delivered but they do not deliver the medications to the facility. W1 stated the pharmacy does not tell the facility that they have not received the doctor's orders. W1 stated if the pharmacy tells them the pending physician order status, then they can call the family to obtain physician's orders for the medications. For medication's they will ask the family to get through to the doctor to ask the doctor to sign the new prescription order for the refill of medication.

On July 8, 2025, LPA Manuel Monter interviewed residents R1-R7. Residents R1-R6 stated they have been getting their medications. Residents R1-R6 stated they have no concerns when it comes to their medications. Resident R7 was unable to provide LPA a response when asked.

LPA Monter interviewed staff S1-S4. All staff interviewed stated residents are getting their medications. All staff interviewed stated they have no knowledge of any medication errors occurring during their time at the facility.

LPA Monter interviewed Health Services Director (HSD). HSD stated based on his/her time working at the facility, the residents have been getting their medication. HSD stated the facility is now using a new pharmacy for medications.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 5 Out of 6.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 26-AS-20250127135342

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: 07/08/2025

NARRATIVE

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Staff did not provide adequate laundry services to residents in care

On January 27, 2025, the Department received a complaint alleging staff did not provide adequate laundry services to residents in care.

On January 31, 2025, LPA Simi Rai interviewed Executive Director (ED) Kenia Padilla. ED stated some staff were not able to come to the facility due to being sick themselves, so ED stated she had hired agency to help with laundry services in the facility. ED stated they had agency staff in the community to help with laundry services. Based on records reviewed, the facility did hire agency services for the facility, for the month of January 2025.

LPA Rai made the following observations during the complaint investigation: LPA Rai observed the laundry room. LPA Rai observed 3 washers, and 2 dryers. One dryer was out of service, but it is going to be repaired.

On July 8, 2025, LPA Manuel Monter interviewed residents R1-R7. Residents R1-R6 stated they have not had any issues regarding their laundry. Residents R1-R6 stated they have not had any delays with their laundry service. Resident R7 was unable to respond to questions LPA posed.

LPA Monter interviewed staff S1-S4. All staff interviewed stated the facility's laundry and dryer machines are functional. Staff S3 & S4 stated there has been a time when one of the washer machines was not working, but both staff interviewed stated maintenance fixed the washer machine.

LPA Monter interviewed Health Services Director (HSD). HSD stated the facility washing machines and dryers are functional. HSD stated if they were to have any issues, they can call maintenance to fix it.

During the tour of the facility, LPA observed the facility washer machines and dryers as functional.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 6 Out of 6.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC9099 (FAS) - (06/04)

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