435294024-7-20-2023-26-AS-RMAO-CUZU94-20230824152232

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294024
Report Date: 07/19/2023
Date Signed: 07/20/2023 08:38:15 AM

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
10/25/2021 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20211025083728

FACILITY NAME:	PACIFIC GARDENS		FACILITY NUMBER:	435294024
ADMINISTRATOR:	ZAHODNE, MATTHEW		FACILITY TYPE:	740
ADDRESS:	2384 PACIFIC DR		TELEPHONE:	(408) 985-5252
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	104	CENSUS: 59	DATE:	07/19/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Administrator Matthew Zahodne		TIME COMPLETED:	07:30 PM

ALLEGATION(S):

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Staff member yells at residents.
Staff member is not administering medications as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Simi Rai and Manuel Monter and Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced inspection/investigation visit to conclude and deliver investigation of the above allegations. LPAs and LPM met with Administrator Matthew Zahodne and stated the purpose of today's visit.

On 10/25/2021, the Department received allegations that staff yells and did not administer medications as prescribed per reporting party (RP). However, RP did not provide names of staff who were yelling and not administering medications as prescribed.

Continuation on LIC 9099-C.
Page 1 of 2.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

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 2

Control Number 26-AS-20211025083728

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: PACIFIC GARDENS	FACILITY NUMBER: 435294024
	VISIT DATE: 07/19/2023

NARRATIVE

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On 11/3/2021, the Department conducted interviews with 7 staff and 6 residents. Based on interview, 7 Out of 7 staff denied allegation that staff members have yelled at residents. 6 Out of 6 residents are not aware of any staff yelling at him/her and/or towards any residents. On 07/19/2023, LPA Rai conducted a random review of 2021 medication records of 3 residents (R1 to R3). Based on medication record review, 3 Out of 3 residents records did not show that medication technician did not administer medications as prescribed. During the pandemic, the staff were wearing masks and it was harder for residents to hear the staff talking through the mask.

On 07/19/23, the Department interviewed 3 staff (S1 to S3), staff denied allegation of not administering medication per doctor's order. They stated the only time when residents' medications were not given is when a resident or residents refuse(d), nor observed staff provided incorrect medication to a resident.

On 07/19/2023, LPA Rai conducted a random review of 2021 medication records of 3 residents (R1 to R3). Based on medication record review, 3 Out of 3 residents records did not show that medication technician did not administer medications as prescribed.

The Department has investigated the complaint allegation. Based on observation, interview, and record review the Department found the complaint allegations are UNFOUNDED, meaning the allegations are false, could not have happened and/or without a reasonable basis.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Matthew Zahodne, Administrator and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

LIC9099 (FAS) - (06/04)

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