435294212-10-18-2023-26-AS-KHOS-CY22DN-20231128161836

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294212
Report Date: 10/18/2023
Date Signed: 10/18/2023 04:54:26 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/03/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20211103114832

FACILITY NAME:	PERPETUAL HELP CARE HOME		FACILITY NUMBER:	435294212
ADMINISTRATOR:	CARUZ, VIRGILIO O.		FACILITY TYPE:	740
ADDRESS:	1888 ARROYO DE PLATINA		TELEPHONE:	(408) 258-1434
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95116
CAPACITY:	6	CENSUS: 6	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Lucena Caruz		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulted in resident elopement from the facility.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Administrator (ADM) Lucena Caruz.

On 11/3/2021, the Department received a complaint with the allegation that Lack of supervision resulted in resident elopement from the facility.

On 11/12/2021, an initial investigation visit was conducted, the Administrator and two staff were interviewed. Resident records including admission agreement, assessments, medical discharge records and medication log were obtained.

Continue on LIC9099-C. Page 1 of 3.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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 4

Control Number 26-AS-20211103114832

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PERPETUAL HELP CARE HOME	FACILITY NUMBER: 435294212
	VISIT DATE: 10/18/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Lack of supervision resulted in resident elopement from the facility:

On 11/12/2021, the Department interviewed staff S1. S1 stated on 9/26/2021 morning, he/she was helping residents to get up and saw resident R1 sitting on his/her bed. S1 stated staff S2 was cooking breakfast in the kitchen. S1 stated when the breakfast ready, he/she went to get R1 for breakfast, and found R1 was not in the bedroom. S1 stated he/she started to look for R1 in the house and backyard but was unable to find R1. S1 stated he/she told S2 that R1 was missing, and S2 went outside to look for R1. S1 stated the facility had front door alarm, but he/she did not recall that he/she heard the alarm.

On the same day, the Department interviewed staff S2. S2 stated on 9/26/2021 morning, he/she was cooking breakfast in the kitchen and saw R1 was in the living room. S2 stated that when breakfast was ready, they found R1 was missing. S2 stated he/she went outside to look for R1 and drove the car to look for R1 at the neighborhood. S2 stated when he/she returned to the facility, he/she found police officer brought R1 back to the facility. S2 checked R1 and R1 was not injured. S2 stated the facility had the front door alarm and it would sound when the front door was opened. S2 stated he/she did not hear the front door alarm sounded on 9/26/2023 morning.

On the same day, the Department interviewed the Administrator (ADM). ADM stated staff S1 and S2 were on duty on 9/26/2021 morning when R1 walked out from the facility without notice. ADM stated the standard procedures for staff to follow are to check the home and then the surrounding area, and to call the Administrator and the police department to file a missing person's report. ADM stated the facility did not call police because when S2 finished searching of neighborhood and returned to the facility, the police officer already brought R1 back to the facility.

ADM stated the facility already replaced a new louder front door alarm, and the facility staff regularly check residents hourly. ADM stated R1 wanted to go home and did not want to stay at care home facility. ADM stated the family member of R1 decided to take R1 home and might look for a new facility to place R1.

On 11/12/2021, LPA checked the new louder front door alarm, and it was working.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20211103114832

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PERPETUAL HELP CARE HOME	FACILITY NUMBER: 435294212
	VISIT DATE: 10/18/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Reviewing R1's medical documents, R1 was ambulatory, was diagnosed dementia and sometimes confused. Based on the interviews conducted, the facility staff were not aware of R1 going out the facility without notice, nor the front door alarm was heard ringing. R1 was wandering outside the facility, and was found by police officers. R1 was brought back to the facility by police officers. The facility did not call police to report a missing person.

The Department has investigated the above allegation. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D.

Exit interview conducted with ADM. The report was provided to ADM for signature. A copy of this report was provided to ADM. Appeal Rights was provided.

Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20211103114832

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PERPETUAL HELP CARE HOME	FACILITY NUMBER: 435294212
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/19/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall... include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated to submit a plan of correction by the POC due date and schedule training to staff to prevent resident elopment.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews, and records reviewed, Staff did not ensure resident (R1) who can’t leave facility unassisted was supervised while leaving the facility. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4