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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294024
Report Date: 07/19/2023
Date Signed: 07/20/2023 08:37:43 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
12/20/2021 and conducted by Evaluator Simranjit Rai
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20211220140640
FACILITY NAME:PACIFIC GARDENSFACILITY NUMBER:
435294024
ADMINISTRATOR:ZAHODNE, MATTHEWFACILITY TYPE:
740
ADDRESS:2384 PACIFIC DRTELEPHONE:
(408) 985-5252
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY:104CENSUS: 59DATE:
07/19/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Matthew ZahodneTIME COMPLETED:
08:00 PM
ALLEGATION(S):
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Staff do not distribute resident's 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 12/20/2021, the Department received allegation that staff did not administer medications as prescribed per reporting party (RP). However, RP did not provide names of staff who did not administer medications as prescribed.

On 12/30/2021, LPA Marrufo met with 3 staff including Administrator. Based on staff interviews, staff denied that they were not following residents' prescribed medication. On 10/25/2021, the Department received same allegation wherein on 11/3/2021, the Department conducted interviews with 7 staff and 6 residents. 6 Out of 6 residents are not aware of any staff yelling at him/her and/or towards any residents.

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-20211220140640
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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Page 2 of 2
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.

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.

The Department has investigated the complaint allegation. Based on observation, interview, and record review the Department found the complaint allegation is UNFOUNDED, meaning the allegation is 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)
Page: 2 of 2