435202895-2-19-2025-26-AS-RMAO-DEE6ZU-20250302201540

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202895
Report Date: 02/19/2025
Date Signed: 02/19/2025 04:07:29 PM

Unfounded

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
12/27/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20241227173840

FACILITY NAME:	MORNINGSTAR ASSISTED LIVING OF WEST SAN JOSE		FACILITY NUMBER:	435202895
ADMINISTRATOR:	WELCH, JOYCE		FACILITY TYPE:	740
ADDRESS:	1380 S DEANZA BLVD		TELEPHONE:	(669) 295-6500
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY:	149	CENSUS: 82	DATE:	02/19/2025
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Blyth Obien		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Due to staff neglect or lack of supervision, a resident R1 left the facility unassisted.
The facility did not send a written incident report when a resident R1 left the facility unassisted to Licensing office.
The facility does not have an appraisal needs and service plan for resident R1.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver an investigation visit and met with Wellness Director Blyth Obien (OB) .

On 12/27/2024, the Department received a complaint with the above allegations.

On 1/3/2024, the Department conducted an initial investigation visit.

LPA interviewed ED and 3 staff.

LPA requested R1' physician report, pre appraisal, service/care plan, and admission agreement.

Continue on LIC9099-C. page 1 of 4.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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 4

Control Number 26-AS-20241227173840

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: 02/19/2025

NARRATIVE

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Due to staff neglect or lack of supervision, a resident R1 left the facility unassisted:
The allegation is that resident R1 left the facility unassisted due to facility staff neglect or lack of supervision.

On 1/3/2025, LPA interviewed Executive Director (ED) Joyce Welch. ED stated R1 moved in 12/10/2024, and lives in assisted Living unit. ED stated on 12/23/2024, around 11:00AM - 11:30AM, he/she received a phone from a kitchen staff who was driving to facility to work and saw R1 was walking away from the facility. ED stated he/she went out to look for R1 and saw R1 was walking in a distance. ED stated he/she called the facility activity director (AD) who was driving the facility vehicle back to the facility to find R1 and to get R1 back to the facility. ED stated AD found R1 after R1 had bought cigarette at gas station and was walking back to the facility. ED stated R1 returned to the facility with AD before 12:00PM and was observed without any injury. ED stated the facility staff notified R1's responsible party the incident. ED stated R1 is able to leave the facility unassisted based on R1's physician report.

LPA interviewed staff (S1). S1 stated R1 usual goes out to smoke outside the main entrance and returns to the facility when R1 finishes smoking. S1 does not know if R1 can leave the facility by himself or not. S1 stated on 12/23/2024 around 11:00AM, R1 went out from main entrance to smoke outside and later R1 was found walking to gas station to buy cigarette. S1 stated R1 returned to the facility with Activity Director AD before 12:00PM. S1 stated R1 directly walked to the dining room for lunch after R1 returned to the facility. S1 stated R1 usually goes outside to smoke and returned to the facility. S1 stated this is the first time R1 walked to gas station to buy cigarette. S1 stated after the incident, R1 needs to sign out and sign in at the front desk.

LPA interviewed Assisted Living Coordinator (ALC). ALC stated he/she was informed the incident. ALC stated on 12/23/2024 around 11:00AM - 11:30AM, R1 walked to 2 blocks away gas station to buy cigarette. ALC stated a staff saw R1 was walking away from the facility and called ED. ED called activity director AD to pick up R1. ALC stated R1 returned to the facility before noon with AD. ALC stated R1 was evaluated without any injury after R1 retuned to the facility.

LPA interviewed Wellness Director (WD), the facility Nurse. WD stated he/she is the one notified R1's responsible party. WD stated R1 was evaluated without any injury after R1 returned to the facility. WD stated he/she reviewed R1's physician report before he/she notified R1's responsible party.
Continue on LIC9099-C. Page 2 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20241227173840

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: 02/19/2025

NARRATIVE

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WD stated R1 is able to leave the facility unassisted. WD stated FM told him/her that R1 is able to leave the facility by self.

On 1/3/2025, LPA interviewed resident R1's family member (FM). FM stated R1 is able to leave the facility unassisted. FM stated the facility staff notified him/her the incident.

FM stated after the incident, he/she and the facility agree that R1 needs to sign out and sign at the front desk. FM stated he/she is looking for day program for R1. FM stated R1 will have day program on Monday, Wednesday and Friday.

Based on the review of R1's physician report dated 12/12/24, R1 is able to leave facility unassisted.

The facility did not send a written incident report when a resident R1 left the facility unassisted to Licensing office.
On 1/3/2025, LPA interviewed Executive Director (ED). ED stated resident R1 is able to leave the facility unassisted based on R1's physician report dated 12/12/2024. ED stated this case is not an elopement.

LPA interviewed Wellness Director (WD). WD stated R1 is able to leave the facility unassisted. WD stated this is not an elopement. WD stated he/she notified R1's responsible party about R1's incident and R1's responsible party told him/her that R1 is able to leave the facility unassisted.

ED stated This is the first time R1 walked out from the facility. A kitchen staff saw R1 walked away from the facility while he/she was driving to facility and called ED. ED went out to look at R1 and found R1 was walking away from the facility. ED asked facility activity director (AD) who was driving the facility car to the facility to drive the facility car to take R1 back to the facility. ED stated R1’s pre assessment was done by him/her. The pre assessment specifies R1 does not need service/care which means R1 is independent.

LPA interviewed Assisted Living Coordinator (ALC). ALC stated R1 is independent and is able to leave the facility unassisted. ALC stated this is not an elopement.

LPA interviewed R1's Responsible Party. R1's Responsible Party stated R1 is able to leave the facility unassisted based on the physician report. Continue on LIC9099-C. Page 3 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20241227173840

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: 02/19/2025

NARRATIVE

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The facility does not have an appraisal needs and service plan for resident R1:

On 1/3/2025, LPA interviewed Executive Director (ED). ED stated resident R1 moved in the facility on 12/10/2024. ED stated the facility has R1's preplacement appraisal form signed by the facility and by R1's responsible Party.

ED stated the facility has R1's admission agreement dated 11/27/2024 and were signed by the facility and R1's responsible party.

ED stated the facility has R1's Individual Service Plan crated on 12/17/2024 in the facility computer system and is keeping updating. ED stated the facility will have the service plan ready when R1 has moved in the facility for 30 days, and to discuss with R1's responsible Party and to sign by R1's responsible party.

The Department has investigated the above allegations. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview conducted with OB. This report was provided to review and for signature. A copy of this report was provided to OB.

Page 4 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4