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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 07/08/2025
Date Signed: 07/08/2025 05:13:45 PM

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
10/24/2024 and conducted by Evaluator Marcella Tarin
COMPLAINT CONTROL NUMBER: 26-AS-20241024102358
FACILITY NAME:MORNINGSTAR MEMORY CARE AT SAN TOMASFACILITY NUMBER:
435202874
ADMINISTRATOR:PADILLA SANCHEZ, KENIAFACILITY TYPE:
740
ADDRESS:3930 WILLIAMS RDTELEPHONE:
(669) 201-2015
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:82CENSUS: 24DATE:
07/08/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Krystal Jenkins, Regional Operations SpecialistTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff are mismanaging resident's medication
INVESTIGATION FINDINGS:
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On 10/24/2024 the Department received a complaint with the above allegation. On 10/31/2024 LPAs conducted the initial 10-day investigation.

On 10/31/2024 LPAs Monter and Fortes audited medications for R1 to R3. During audit of R3’s medications, Medication M1 had a bubble pack that contained medication logded between the plastic and was not administered.

Based on review of R1’s Medication Administration Record (MAR), the medication in the bubble pack (listed as #28 in the MAR), was listed as ‘administered.’ Review of the MAR, LPAs observed R1 did not receive medication M1.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
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 3
Control Number 26-AS-20241024102358
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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Based on review of R1’s physicians report dated 8/9/2024, R1 is unable to administer his/her own medications.

On 10/25/2024 LPA Christine Dolores received a voicemail and email from S1 to self-report medication errors. LPA Dolores spoke with S1 who stated the facility was reporting medication errors for 2 residents. S1 stated a plan of correction was being conducted with nurses and medtechs.

On 7/8/2025 LPAs Monter and Tarin conducted a random audit of 4 Residents. During audit, LPAs observed medication discrepancies for R8. LPAs observed Medication M1, which states “Take 1 tab by mouth in the morning, before breakfast.” LPAs reviewed Medication M1’s bubble pack and observed the tablet on #8 was still inside the bubble pack. The bubble pack states the medication was opened on 7/1/2025. A review of R8’s Medication Administration Record (MAR) states that R8 was administered M1 from 7/1/2025 to 7/8/2025 at 6:00AM.

Based on review of R8’s physicians report dated 12/20/2023, R8 is unable to administer his/her own medications.

LPAs interviewed Health Services Director (HSD). HSD stated she was not informed of any refusal by staff. LPAs asked if HSD could explain what occurred. HSD stated, “I don’t know.”

During audit of residents R7 to R10, LPAs noted that each resident has medications that were not listed on the Centrally Stored Medication log.

LPAs interviewed Health Services Director (HSD). HSD stated “I don’t know. Maybe the med-techs didn’t central log it.” HSD did not provide additional information.

Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations (Title 22), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
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 3
Citations on this Visit Report are Under Appeal!

Control Number 26-AS-20241024102358
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: 07/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
07/09/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs

This requirement was not met as evidenced by
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Licensee states the facility will conduct additional medication administration training by 7/15/2025. Licensee will submit the Plan of Correction (POC) by POC due date 7/9/2025, and submit completion of training to the Department.
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Based on investigation, R8 requires assistance with medication administration. Resident medication M1 was not administered on 7/8/2025. HSD stated "I don't know" regarding the discrepancy, which poses an immediate health, safety and personal rights risk to residents in care.
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Under Appeal
Type B
07/15/2025
Section Cited
CCR
87465(h)(6)(A-F)
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87465 Incidental Medical and Dental Care
(h)(6)(A-F) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...

This requirement was not met as evidenced by
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Licensee states the facility will conduct additional medication administration training by 7/15/2025. Licensee will submit the Plan of Correction (POC) by POC due date 7/9/2025, and submit completion of training to the Department
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Based on investigation, R7 to R10, LPAs noted that each resident has medications that were not listed on the Centrally Stored Medication log. HSD stated, "I don't know" regarding the discrepancies, which poses an immediate health, safety and personal rights risk to residents in care.
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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: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
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