435294025-12-1-2022-26-AS-KHOS-CM3PEF-20221213101503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294025
Report Date: 12/01/2022
Date Signed: 12/01/2022 02:58:49 PM

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
11/22/2022 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20221122172355

FACILITY NAME:	PENDAR'S RESIDENTIAL CARE		FACILITY NUMBER:	435294025
ADMINISTRATOR:	MILA VALISTO		FACILITY TYPE:	740
ADDRESS:	524 SAFARI DRIVE		TELEPHONE:	(408) 578-8488
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 2	DATE:	12/01/2022
		UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Mila Valisto		TIME COMPLETED:	02:59 PM

ALLEGATION(S):

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Staff did not seek medical attention for resident in a timely manner
Staff do not ensure resident's hygiene needs are met
Facility is not following resident's dietary needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) arrived at the facility to open a complaint investigation regarding the above allegations. LPA met with facility Administrator Mila Valisto (Admin).

During the course of the investigation, LPA toured the facility, interviewed 2 residents, 1 staff, and 1 witness. In interviews with facility residents (R1 & R2), When asked about how often they receive showers per week, both residents indicated that they are showered regularly, and that they receive more than one shower per week. LPA observed the residents to be clean and odorless. In interview with witness (W1) to facility activity, W1 indicated that they had not arrived at the facility to find residents dirty before.

Continued in 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20221122172355

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: PENDAR'S RESIDENTIAL CARE	FACILITY NUMBER: 435294025
	VISIT DATE: 12/01/2022

NARRATIVE

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In review of facility documents, no residents currently living at the facility have doctor proscribed dietary restrictions. In R1's care plan, it is stated that they should not receive extra salt with their meals. When LPA interviewed R1 and R2, both stated that they are served three meals a day every day. Both residents stated that they do not have a problem with the serving size or taste of food provided. In interview with W1, W1 stated that R1 has some trouble chewing, but that the doctor has not prescribed a specialized meal plan. W1 stated that R1 is currently underweight, so the facility has begun serving R1 protein shakes as a supplement.

During review of facility records, LPA did not see any indication of residents at the facility experiencing medical emergencies or requiring specialized medical care within the past year. In interview, W1 stated that they were not aware of any instance in which a resident was not provided medical assistance when needed. W1 stated they were not aware of any recent emergencies. In interview with Admin, Admin stated that R1 is sometimes taken to the doctor by their responsible party, but that there have been no recent instances that required medical treatment outside of the general care giving scope of the facility.

Based on information from LPA observation, interviews conducted, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED.

No deficiencies cited under Title 22 during this visit. Report was reviewed with and signed by Administrator Mila Valisto and a copy was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
11/22/2022 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20221122172355

FACILITY NAME:	PENDAR'S RESIDENTIAL CARE		FACILITY NUMBER:	435294025
ADMINISTRATOR:	MILA VALISTO		FACILITY TYPE:	740
ADDRESS:	524 SAFARI DRIVE		TELEPHONE:	(408) 578-8488
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 2	DATE:	12/01/2022
		UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Mila Valisto		TIME COMPLETED:	02:59 PM

ALLEGATION(S):

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Staff do not provide information about the resident's care to authorized persons

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) arrived at the facility to open a complaint investigation regarding the above allegations. LPA met with facility Administrator Mila Valisto (Admin).

During investigation, LPA reviewed power of attorney agreements for all residents at the facility who had one. In review of power of attorney agreements, LPA identified R1's current power of attorney. In interview with R1's power of attorney (POA), POA stated that they have never been denied accress to resident records from the facility. Review of R1's power of attorney agreement indicates that POA has sole durable authority over R1's care.

This Department has investigated the above allegation. Based on interviews conducted, and records reviewed, the Department has found that this allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted with licensee/administrator. A copy of this report was provided for signature.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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