435294024-7-18-2025-26-AS-RMAO-DKCTBK-20250808143517

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294024
Report Date: 07/18/2025
Date Signed: 07/18/2025 11:46:27 AM

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
03/04/2025 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20250304144818

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: 70	DATE:	07/18/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Director of Resident Care Services, Vina Estella		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care.
Facility staff did not seek timely medical attention for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Director of Resident Care Services, Vina Estella and stated the purpose of today’s visit.

On 03/04/2025, the Department received a complaint with the above allegations. On 03/05/2025, the Department conducted an initial investigation at the facility.

It was alleged that resident (R1) sustained an unexplained injury while in the care of the facility and facility staff did not seek timely medical attention for R1 related to the injury.

Continuation on LIC 9099-C, Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

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-20250304144818

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: 07/18/2025

NARRATIVE

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Page 2 of 3.

On 3/3/2025, the facility reported on LIC 624 Incident Report regarding facility staff observed resident (R1) bleeding from the left elbow. The facility staff provided necessary first aid by cleaning the area and applied bandage. The facility staff assessed R1 and R1 did not complain of being in pain and had the ability to move the left arm. R1 did not recall how he/she sustained the injury.

On 3/17/2025, the Department interviewed Witness (W1). W1 stated the facility staff did inform W1 regarding R1’s “scratch” which occurred on 3/3/2025 and staff were not able to say how the scratch occurred. W1 stated R1 was admitted to the hospital on 3/3/2025 for pneumonia, hip fracture and swollen feet.

On 3/28/2025, the Department interviewed six staff (S1-S6). Three out of six staff stated they did not observe bruises or injuries prior or 3/3/2025. Two out of six staff stated there were no issues report regarding R1 during nocturnal shift, the night before 3/3/2025. Two out of six staff stated R1 was found with a bruise the day of 3/3/2025. Three out of six staff stated they did not observe any falls or incidents related to R1.

Two out of the six staff stated R1 was a fall-risk resident. Three out of six staff stated they observed bruises on R1 which were self-inflicted during R1’s behavioral expression when R1 was agitated. S2 stated R1 has a habit of swinging arms when R1 is agitated. S5 assessed R1 on 3/3/2025 when R1 was bleeding from elbow and required first aid assistance. S5 assessed R1’s upper extremities and provided first aid care by applying a band aid over the elbow. S5 stated R1 was not in pain which was assessed through R1’s facial expression and verbal confirmation. S5 stated he/she observed R1 did not have pain in his/her legs therefore S5 did not assess R1’s lower extremities.

On 6/3/2025, the Department interviewed three residents (R1-R3). Three out of three residents stated they were not aware of R1’s injury or incidents involving R1. Three out of three residents stated the facility staff are available to provide care and assistance if needed. Three out of three residents stated the facility staff check up on them regularly.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20250304144818

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: 07/18/2025

NARRATIVE

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Page 3 of 3.

Based on review of R1’s Progress Notes dated 3/2/2025, R1 was observed by facility staff to be sitting on the floor, staff attempted to assist R1 but R1 was agitated. After staff’s requests, R1 stood up and sat on the sofa. Based on review of R1’s Progress Notes in February 2025, there were no notes regarding incidents involving R1 falling or unusual incidents, but there were notes regarding R1’s repetitive behavior regarding R1’s refusal for staff assistance, spitting and wandering. Based on review of R1’s Appraisal dated 1/20/2025, R1 is non-ambulatory and is not able to walk without physical assistance wherein R1 uses a walker. R1 does not require assistance transferring in and out of bed/turning in bed or chair.

Based on review of documented meeting notes between Facility staff, including Administrator (ADM) Matt Zahodne and R1’s responsible party, three meetings took place between 2/18/2025 – 3/3/2025. All three meetings were regarding R1’s aggressive behavior towards staff and residents.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Director of Resident Care Services, Vina Estella and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

LIC9099 (FAS) - (06/04)

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