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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202895
Report Date: 10/17/2024
Date Signed: 10/17/2024 05:04:44 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
04/16/2024 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20240416164940
FACILITY NAME:MORNINGSTAR ASSISTED LIVING OF WEST SAN JOSEFACILITY NUMBER:
435202895
ADMINISTRATOR:WELCH, JOYCEFACILITY TYPE:
740
ADDRESS:1380 S DEANZA BLVDTELEPHONE:
(669) 295-6500
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:149CENSUS: 58DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Joyce WelchTIME COMPLETED:
11:16 AM
ALLEGATION(S):
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Lack of supervision resulted in Resident on Resident Altercation.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Joyce Welch.

On 4/16/2024, the Department received a complaint with the allegation that facility staff lack of supervision resulted in resident on resident alterations.

On 4/19/2024, the Department conducted an initial investigation visit. LPA interviewed ED, a staff, a resident and a private companion.

LPA requested resident roster, LIC500, resident physician report, appraisal needs and service plan, and incident reports.

Continue on LIC9099_C. Page 1 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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-20240416164940
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 ASSISTED LIVING OF WEST SAN JOSE
FACILITY NUMBER: 435202895
VISIT DATE: 10/17/2024
NARRATIVE
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Lack of supervision resulted in Resident on Resident Altercation:
The allegation is that facility staff lack of supervision resulting in on 4/10/2024 around 3:30PM, a resident R1 wandering into another resident R2's room and having alteration between R1 and R2. Both R1 and R2 live in the memory care unit.

On 4/19/2024, LPA interviewed Executive Director (ED) Joyce Welch. ED stated on 4/10/2024, resident R1 entered resident R2's room. R1 has neurocognitive impairment and thought that is R1's room. R2 asked R1 to leave the room and R1 got mad. R2 has a private companion (PC1) at that time. PC1 stated R2 told PC1 that R1 attacked R2 but PC1 stated he/she did not observe it.

LPA interviewed PC1. PC1 stated he/she was in the restroom when the incident occurred. PC1 stated he/she did not see R1 attacked R2 but he/she saw R1 in R2's room when he/she exited from the restroom. PC1 stated he/she asked R1 to leave R2's room.

LPA interviewed resident R2. R2 has neurocognitive impairment. R2 stated he/she cannot recall the incident. R2 stated the facility has a good environment to live. R2 stated he/she likes the facility.

LPA interviewed Wellness Director (S1). S1 stated R2 has private companion from 6:00AM to 6:00PM Monday to Saturday. S1 stated on 4/10/2024, he/she received a report that resident R1 entered resident R2's room and R1 and R2 had altercation. S1 stated he/she went to R2's room immediately and R1 already left R2's room. S1 assessed R2 immediately. S1 stated he/she did not find any injury on R2, and R2 stated he/she is fine. S1 stated he/she notified Police, Ombudsman, CCL office and resident families immediately. S1 stated after the incident, the facility provided a week's staff training to prevent the similar incident to occur.
R1 moved in the facility on 4/2/2024. R1 did not have similar incident before during 9 day's stay in the facility.

Based on the review of R1's Pre-Admission evaluation document dated 3/17/2024, R1 has neurocognitive impairment, elopement, exit seeking/wandering and needing occasional intervention.
Based on the review of the LAW Enforcement Task Report, the R2 had no visible injuries. and this is the R1's first incident.
Continue on LIC9099-C. Page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20240416164940
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 ASSISTED LIVING OF WEST SAN JOSE
FACILITY NUMBER: 435202895
VISIT DATE: 10/17/2024
NARRATIVE
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Based on documents 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 allegation did or did not occur.

No citation noted today. Exit interview was conducted with ED. A copy of the report was provide to ED.

Page 3 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20240416164940
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 ASSISTED LIVING OF WEST SAN JOSE
FACILITY NUMBER: 435202895
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2024
Section Cited
CCR
87464(f)(1)
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87464 Basic Services(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).

This requirement is not met as evidenced by:
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Administrator stated to submit a plan of correction by the POC due date to ensure residents to receive necessary care and supervision, and to provide staff training to prevent similar incident to happen. Administrtor to submit the staff training log to CLL office.
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Based on interview and record review, the facility did not provide the necessary care and supervision to resident R1 to meet R1's care needs and leading to R1's wandering into R2's room and had altercation with R2, which poses/posed an potential Health, Safety, or Personal Rights risk to persons 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: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4