435294206-7-26-2024-26-AS-KHOS-D8BJKE-20240820070701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294206
Report Date: 07/26/2024
Date Signed: 07/26/2024 12:47:58 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2022 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220831120143

FACILITY NAME:	KIMBERLY'S ELDER KARE KOTTAGE		FACILITY NUMBER:	435294206
ADMINISTRATOR:	KENDALL HALL		FACILITY TYPE:	740
ADDRESS:	2770 MOORPARK AVENUE		TELEPHONE:	(408) 483-1029
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	6	CENSUS: 4	DATE:	07/26/2024
		UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Annabelle Esperanza		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care
Staff refused to administer residents medication
Staff did not notify residents authorized representatives in a timely manner of incidents
Residents were left unsupervised
Staff restricted resident from having visitors

INVESTIGATION FINDINGS:

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On 7/26/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Annabelle Esperanza and explained the purpose of today's visit.

Regarding the allegation of Resident sustained multiple pressure injuries while in care, Reporting Party (RP) stated that when RP came back after an out of town event, hospice was there, and they rolled resident (R1) onto their side and found that R1 had bedsores from neck down to R1s feet.

LPA Dolores was able to interview two staff members. One staff (S1) stated that R1 developed bed sores but hospice addressed that and it healed. Staffing in the facility is 2 caregivers per shift. Each caregiver check on resident every two hours to rotate the resident. It was also stated that a family member (F1) didn't want the staff to take R1 out of bed because if staff move R1, he/she'd be in pain.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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-20220831120143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: KIMBERLY'S ELDER KARE KOTTAGE	FACILITY NUMBER: 435294206
	VISIT DATE: 07/26/2024

NARRATIVE

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Regarding the allegation that staff refused to administer residents’ medication. RP stated that when R1 returned to the facility, hospice was brought in two day a week to care for R1. RP stated that they had put R1 on morphine twice a day and staff (S3) didn’t want to give resident the medication because he/she was too heartbroken about R1s condition dwindling.

During the interview, S1 and S2 mentioned that R1 was given morphine and the staff are not allowed to fill the syringe. Hospice needs to do it. A nurse comes to give it to R1.

Based on records review, the staff are able to assist the resident by giving morphine which is in tablet form and also a PRN. Facility has showed records of days where PRN medication was administered and documented results.

Regarding the allegation of staff did not notify residents authorized representatives in a timely manner of incidents, RP stated that R1 had a UTI in April, and the facility staff did not call the family to inform them. The staff called an ambulance at 6pm and staff did not call family when R1 was already at the hospital.

According to S2, during this time R1 had a fever and S2 called the responsible party/POA and was advised to bring R1 to the hospital.

Regarding the allegation of residents were left unsupervised, RP stated that R1 had been sitting in a soiled diaper and the padding on the bed was brown which means that it hadn’t been changed in a while, when RP went to look for staff, no one was around.

According to S1, the Licensee (L1) came to the facility immediately when it was reported that there was no staff. S2 arrived 2 seconds from L1 and saw 1 caregiver. Three other Staff members, S4, S5 & S6 was at the facility at that time. During this time, S6 was on break. S5 was at the other part of the house helping another resident.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20220831120143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: KIMBERLY'S ELDER KARE KOTTAGE	FACILITY NUMBER: 435294206
	VISIT DATE: 07/26/2024

NARRATIVE

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Regarding the allegation of staff restricted resident from having visitors, RP stated that after the death of R1, RP tried to go back and visit another resident (R2) and the administrator wouldn’t let him/her in. RP stated that this R2s responsible party came to visit and called RP saying that R2 wanted to see him/her.

Based on interviews, S1 mentioned that RP came back to the facility to visit another resident, who RP became friends with. RP was allowed to visit R2. S2 also confirmed that RP was able to visit R2 during that day.

Based on records review, visitation logs show that RP was able to enter the facility and visit R2.

Based on interviews & records review, the department has determined that although the allegation 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.

Report is reviewed and copy is provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC9099 (FAS) - (06/04)

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