435294079-11-5-2024-26-AS-KHOS-DAXQ2L-20241112104719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294079
Report Date: 11/05/2024
Date Signed: 11/05/2024 05:11:08 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
02/09/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20240209092923

FACILITY NAME:	RIVER PARK HOMES II		FACILITY NUMBER:	435294079
ADMINISTRATOR:	GARCIA, AMPARO QUE		FACILITY TYPE:	740
ADDRESS:	3427 GILA DRIVE		TELEPHONE:	(408) 270-4060
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY:	6	CENSUS: 2	DATE:	11/05/2024
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Amparo Que Garcia		TIME COMPLETED:	04:38 PM

ALLEGATION(S):

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Facility is not adhering to infection control plan.
Facility did not notify residents' family and other agencies of current covid outbreak.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Administrator (ADM) Amparo Que Garcia.

On 2/9/2024, the Department received a complaint with the above allegations.

On 2/15/2024, the Department conducted an initial investigation visit. LPA interviewed ADM, 2 staff and 4 residents.

LPA toured the facility and checked the PPE supplies.

Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024

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-20240209092923

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: RIVER PARK HOMES II	FACILITY NUMBER: 435294079
	VISIT DATE: 11/05/2024

NARRATIVE

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Facility is not adhering to infection control plan:
The allegation is that a home care nurse did not receive a notice of 2 resident and 1 staff with COVID positive in the facility until he/she visited the facility on 2/8/2024, at 9:15AM, and observed 2 staff without wearing masks and were not adhering to infection control plan.

On 2/15/2024, LPA visit the facility and interviewed Administrator (ADM) Amparo Que Garcia. ADM stated resident R1 tested COVID positive on 2/4/2024 and resident R2 tested positive on 2/5/2024. ADM stated R1 and R2 were isolated at their private rooms. ADM stated staff S1 tested negative and S2 tested positive on 2/5/2024. ADM stated S1 only takes care of COVID negative residents and S2 only takes care of COVID positive residents.

ADM stated he/she notified local health department and CCL office. ADM stated he/she notified resident families and affected residents' family doctors. ADM stated he/she encouraged visitors not to visit the facility if not necessary. ADM stated on 2/9/2024, S2 was tested COVID negative and R1 and R2 were tested COVID negative on 2/12/2024.

LPA interviewed staff S1. S1 stated he/she only takes care of COVID negative residents during the facility COVID period.

LPA interviewed staff S2. S2 stated he/she only takes care of COVID positive residents during the facility COVID period. S2 stated he/she was wearing PPE when he/she entered R1 and R2's rooms.

During LPA visit, LPA observed S1, S2 and ADM were wearing masks. LPA observed the COVID screening station with visitor log, mask, and thermometer in the main entrance. LPA checked the facility PPE supplies, and PPE supplies were observed sufficient.

LPA interviewed resident R1. R1 just listened to LPA's questions but was unable to answer LPA's question.

LPA interviewed resident R2. R2 stated facility staff took care of him/her during his/her COVID positive period but was unable to tell the name of the staff.
Continue on LIC9099-C. Page 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240209092923

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: RIVER PARK HOMES II	FACILITY NUMBER: 435294079
	VISIT DATE: 11/05/2024

NARRATIVE

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Based on the record reviewed, the facility notified CCL office on the phone on 2/7/2024 and sent the incident report to CCL office on 2/7/2024.

Based on the observation, interview, and records reviewed, no evidence to indicate the facility is not adhering to infection control plan.

Facility did not notify residents' family and other agencies of current covid outbreak:

On 2/15/2024, LPA interviewed Administrator (ADM). ADM stated he/she notified CCL office and local health department. ADM stated he/she notified residents families for the COVID positive cases in the facility. ADM stated the facility notified visitors, including home heath nurse, not to visit the facility if not necessary.

LPA interviewed 4 residents. 2 out 4 residents did not know the facility had COVID cases.

On 2/19/2024, LPA interviewed 2 families of residents. 1 Out of 2 stated the facility notified him/her, the other one stated the facility did not notified him/her of the facility COVID positive cases.

Based on the records reviewed, On 2/7/2024, two LPAs spoke with ADM and instruct ADM to notified local health department, and ADM stated he/she will notified local health department. On 2/7/2024, CCL office received the facility incident report of 3 COVID positive cases at the facility.

Based on documents reviewed, observation, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

No citations noted for today’s visit. Exit interview was conducted with ADM. A copy of this report was provided to ADM.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3