435294206-1-18-2025-26-AS-ACON-DEGMDA-20250305083045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294206
Report Date: 01/18/2025
Date Signed: 01/18/2025 04:01:55 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
05/23/2023 and conducted by Evaluator Arvin Villanueva

COMPLAINT CONTROL NUMBER: 26-AS-20230523085525

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: 5	DATE:	01/18/2025
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Kendall Hall and Annabelle Esperanza		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff interferred with the Long Term Care Ombudsman's facility visit.

INVESTIGATION FINDINGS:

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On 1/18/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct a follow up complaint visit regarding the allegation noted above. LPA initially met with staff on duty and stated the purpose of the visit. The administrators, Kendall Hall and Annabelle Esperanza arrived shortly after. Present during today's visit were 5 residents in care with 2 staff on duty.

The investigation in to the above allegation consisted of interviews and record reviews.

Based on an interview with an Ombudsman representative (Omb), it was revealed that the visiting ombudsman on May 2023 was asked to leave the facility. Omb stated they subsequently spoke with the facility licensee to explain the ombudsman’s role during visits. Omb also disclosed that the ombudsman team was short-staffed at the time and did not become fully staffed until November 2024. Efforts have since been made to resume regular visits. The ombudsman who conducted the May 2023 visit is no longer with the agency and could not provide further information regarding that visit.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2025

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-20230523085525

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: KIMBERLY'S ELDER KARE KOTTAGE	FACILITY NUMBER: 435294206
	VISIT DATE: 01/18/2025

NARRATIVE

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Omb confirmed that they reviewed the photos taken during the May 2023 visit and confirmed that the photos taken did not contain photos of residents and/or staff. Additionally, Omb stated there were no subsequent ombudsman visits to the facility until November 2024 due to staffing challenges. Omb noted that any issues arising during the November 2024 visit would have been reported but confirmed no concerns were brought to their attention.

Interviews with facility staff indicated that during the May 2023 visit, the ombudsman that visited was perceived as rude toward caregivers. Staff also reported that the ombudsman began taking photos of residents without their permission, which prompted staff to intervene to protect residents’ privacy. Staff further stated that follow-up visits by other ombudsman representatives occurred after the incident, during which no issues were reported. According to staff, the most recent ombudsman visit occurred on January 10, 2025, and no concerns were noted during this visit.

A review of past Department visit reports from August 7, 2024, July 26, 2024, May 31, 2023, September 1, 2022, August 3, 2022, and August 25, 2021, found no evidence of facility staff interfering with these visits.

Based on the information gathered during this investigation, 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.

No deficiencies are being cited from today's visit. Exit interview was conducted with the administrators and a copy of this report and appeal rights were provided.

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SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2025

LIC9099 (FAS) - (06/04)

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