435294024-7-20-2023-26-AS-RMAO-CUZSEG-20230824134841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294024
Report Date: 07/19/2023
Date Signed: 07/20/2023 08:38:56 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
08/04/2021 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210804114331

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:	08:00 PM

ALLEGATION(S):

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Resident denied a refund
Staff did not ensure resident ate which resulted in weight loss
Resident's needs were not met

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 8/4/2021, the Department received a complaint with the above allegation. On 8/6/2021, LPA Roadilla conducted the investigation and interviewed Executive Director (ED) and Director of Resident Care Services (DRCS) and requested for resident's records.

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

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
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 3

Control Number 26-AS-20210804114331

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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Resident denied a refund
On 8/6/2021, the Department interviewed Executive Director (ED) via tele-visit. ED stated R1 moved out 2-3 weeks after moving into the facility. R1/R1's Responsibility Party did not give a 30-day notice to the facility and R1/R1's Responsible Party owes partial payment on the rent. ED stated R1 moved into the facility on June 30th 3021 and left the facility July 15th. ED stated R1's Responsible Party signed a contract which states the facility needs to be given a 30 day notice to terminate the agreement and R1's Responsible Party did not provide the notice and facility is still owed 2 weeks of rent.

Based on review R1's Admission Agreement signed by R1's Responsible Party on 6/30/2021. The Admission Agreement stated the "term of the Agreement shall be month-to-month, unless and until it is terminated as set forth in this Agreement." Under Community Fee section of the Admission Agreement section (iii) the document states " If this Agreement terminated and you leave PG, for any reason, during the first month of residency, you will be entitled to a refund of eighty percent (80%) of the balance after a five hundred dollar ($500) fee is deducted." Under the Termination - Termination By Resident, the document stated "You may terminate this Agreement at any time, with or without cause, by giving the Executive Director or his/her designee thirty (30) days' prior written notice of termination." R1's Responsible Party signed the document and agreed to abide by the terms. Based on R1's stay at the facility, which was only 15 days, and R1's Responsible Party not providing a 30-day Notice to the facility, R1's Responsible Party does not qualify for a refund.

Staff did not ensure resident ate which resulted in weight loss
Resident's needs were not met
On 8/6/2021, the Department interviewed Executive Director (ED) via tele-visit. ED stated R1 ate in the dining room constantly and staff documented in his/her care notes about his/her food intake. ED stated R1 liked the soup served in the kitchen. ED stated R1's spouse did not want R1 to consume eggs and the kitchen staff make notes to not serve R1 eggs.

On previous investigation 8/6/2021 by a former LPA, based on LPA Roadilla's investigation, R1's spouse alleged that staff served eggs to R1 and R1 threw up the eggs. ED stated R1 was not served eggs rather it a mashed cauliflower, and kitchen staff was aware of R1's food/diet.
Continuation on LIC 9099-C.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
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 3

Control Number 26-AS-20210804114331

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 3 of 3.
Based on review of R1's records, LIC 602A Physician's Report 5/19/2021, R1 has neuro cognitive disorder and was confused and disoriented and his/her weight was at 185lbs. On 6/30/2021, R1 was admitted in the facility wherein his/her weight was taken on 7/1/21 at 178.9lbs. Based on LIC 603A Appraisal, R1 does not have food allergies but does not like to eat eggs. Based on Care Plan dated 06/29/2021, a note was made on the care plan stating "R1 doesn't like to eat eggs".

On 7/8/2021, R1's spouse and his/her son/daughter visited R1. During visit R1 was sleeping. R1's spouse assumed that R1 was not provided a meal. Per review of staff notes, R1 refused dinner so staff brought dinner to R1's room.

Based on record review and interview, the facility was documenting R1's food consumption. Facility staff made note of days R1 refused food and staff delivered food to R1's room. Based on review of R1's care plan, facility made a note of R1's preference of not eating egg.

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.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
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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