435294224-10-17-2024-26-AS-KHOS-DABQG8-20241023120907

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294224
Report Date: 10/17/2024
Date Signed: 10/17/2024 05:03:49 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
07/10/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20240710154240

FACILITY NAME:	CAMPBELL VILLAGE		FACILITY NUMBER:	435294224
ADMINISTRATOR:	STAMM, ANELLI		FACILITY TYPE:	740
ADDRESS:	290 N. SAN TOMAS AQUINO ROAD		TELEPHONE:	(408) 378-2535
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	90	CENSUS: 66	DATE:	10/17/2024
		UNANNOUNCED	TIME BEGAN:	08:51 AM
MET WITH:	Maria Perlas		TIME COMPLETED:	09:56 AM

ALLEGATION(S):

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Facility staff does not provide assistance to residents in turning and repositioning in bed.
Facility staff does not provide personal care to meet the resident's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver investigation findings and met with Administrative/Marketing Assistant Maria Perlas (MP).

On 7/10/2024, the Department received a complaint with the allegations that facility staff does not provide assistance to resident in turning and repositioning in bed and facility staff does not provide personal care to meet the resident's needs.

On 7/17/2024, the Department conducted an initial investigation visit.

LPA interviewed ADM and 6 staff, and requested resident roster, resident R1's physician report, appraisal Needs and service plan, resident checking log, and progress notes.

Continue on LIC9099-C. Page 1 of 4.

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: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

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 7

Control Number 26-AS-20240710154240

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: CAMPBELL VILLAGE	FACILITY NUMBER: 435294224
	VISIT DATE: 10/17/2024

NARRATIVE

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Facility staff does not provide assistance to residents in turning and repositioning in bed:

The allegation is that resident R1 was observed not being repositioned in bed for several hours by R1's family member.

On 7/16/2024, LPA interviewed R1's family member (FM). FM refused to provide more detail information.

On 7/17/2024, LPA interviewed Administrator (ADM) Geralyn De Ocampo. ADM stated the facility staff reposition bedridden residents every two hours.

LPA interviewed caregiver S1. S1 stated he/she works for AM shift. S1 stated he/she met R1's family member (FM) in the weekend morning, but he/she was unsure on 7/6/2024 or 7/7/2024. S1 stated he/she repositions resident R1 every 2 hours during his/her shift. S1 stated he/she changed R1's diapers and repositioned R1 on 8:00AM, 10:00AM, and 12:15PM, and FM observed that.

LPA interviewed Assisted Living Supervisor (S2). S2 stated he/she was at the facility on 7/7/2024 Sunday night and he/she knew FM was at the facility on 7/6/2024 and 7/7/2024.

LPA interviewed Activity Director (S3). S3 stated he/she was on duty on 7/6/2024 and 7/7/2024. S3 stated FM came in the facility on 7/6/2024 afternoon and 7/7/2024 morning.

LPA interviewed Med Tech and LVN S4. S4 stated he/she worked on 7/6/2024 PM shift and 7/7/2024 AM shift. S4 stated he/she saw FM on 7/6/2024 and 7/7/2024.

LPA interviewed Med Tech and caregiver S5. S5 stated on 7/6/2024 afternoon he/she called R1's hospice care nurse to come to the facility because FM's request.,

LPA interviewed caregiver S6. S6 stated he/she worked on 7/6/2024 3:00PM to 8:00PM. S6 stated he/she repositioned R1 every two hours during his/her shift.

Continue on LIC9099-C. Page 2 of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 26-AS-20240710154240

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: CAMPBELL VILLAGE	FACILITY NUMBER: 435294224
	VISIT DATE: 10/17/2024

NARRATIVE

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Based on the review of R1's Appraisal Needs and Service Plan, R1 needs to be repositioned every 2 hours.,

Based on the review of R1's repositioning Log from 7/6/2024 to 7/11/2024, at 7/6/2024 8:00AM, 10:00AM, and 12:00PM were observed unchecked.

R1's family member FM refused to provide more detail information regarding the allegation. Staff S1 stated he/she repositioned R1 every two hours but was unsure if the repositions were all documented. ADM stated staff are trained and instructed to reposition bedridden residents every two hours.

Facility staff does not provide personal care to meet the resident's needs:
The allegation is that facility staff does not provide personal care to meet resident R1's need and R1 was not being checked every two hours and was observed sweating in R1's room due to the air condition was not working. R1 was under hospice care.

On 7/16/2024, LPA interviewed R1's family member (FM). FM refused to provide more detail information.

On 7/17/2024, LPA interviewed Administrator (ADM). ADM stated resident R1 was under hospice care. and R1's medical and health condition was under the hospice care agency's management and supervision. ADM stated caregivers check R1 every two hours. ADM stated on 7/6/2024 R1 was observed condition change and the facility notified R1's hospice care agency.

LPA interviewed 2 caregivers S1 and S6. Both stated they checked resident R1, changed R1's diapers, and repositioned R1 every two hours.

LPA interviewed staff S2. S2 stated on 7/6/2024, resident R1 changed condition and refused to eat.

Based on the review of R1' checking Log from 7/6/2024 to 7/11/2024, R1 was checked every two hours.
Based on the review of R1 Appraisal Needs and Service Plan, staff to monitor R1's health condition, notify hospice care agency and family when changes in health condition. Comfort medications must be administered by R1's hospice care nurse. Assist R1's ADL at all time.
Continue on LIC9099-C. Page 3 of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 26-AS-20240710154240

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: CAMPBELL VILLAGE	FACILITY NUMBER: 435294224
	VISIT DATE: 10/17/2024

NARRATIVE

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LPA interviewed staff S3. S3 stated FM claimed the air condition of R1's room was not working on 7/6/2024. S3 stated the facility offered to change room for R1 on 7/6/2024. S3 stated FM refused R1 to relocate to another room. S3 stated the air condition of R1's room was fixed on 7/7/2024.

LPA interviewed ADM. ADM stated the air condition of R1's room was not working on 7/6/2024 and the air condition was fixed on 7/7/2024.

Based on the interviews and record reviewed, R1 was checked by the facility staff every two hours. R1's hospice care agency manages R1's health condition. The facility staff notified R1's change in condition to R1's hospice care agency nurse.

Based on documents reviewed, 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 MP. A copy of this report was provided to MP.

Page 4 of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 7

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
07/10/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20240710154240

FACILITY NAME:	CAMPBELL VILLAGE		FACILITY NUMBER:	435294224
ADMINISTRATOR:	STAMM, ANELLI		FACILITY TYPE:	740
ADDRESS:	290 N. SAN TOMAS AQUINO ROAD		TELEPHONE:	(408) 378-2535
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	90	CENSUS: 66	DATE:	10/17/2024
		UNANNOUNCED	TIME BEGAN:	08:51 AM
MET WITH:	Maria Perlas		TIME COMPLETED:	09:56 AM

ALLEGATION(S):

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Facility staff did not properly administer injections.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver investigation finding and met with Administrative/Marketing Assistant Maria Perlas (MP).

On 7/10/2024, the Department received a complaint with the allegation that facility staff did not properly administer injection to resident R1.

On 7/17/2024, the Department conducted an initial investigation visit.

LPA interviewed ADM and 6 staff, and requested resident roster, resident R1's physician report, appraisal Needs and service plan, resident checking log, and progress notes.

Continue on LIC9099-C. Page 1 of 3.

Unfounded

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: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

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

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 26-AS-20240710154240

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: CAMPBELL VILLAGE	FACILITY NUMBER: 435294224
	VISIT DATE: 10/17/2024

NARRATIVE

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Facility staff did not properly administer injections:
The allegation is that the facility staff did not properly administer comfort medications injection for resident R1. R1 was under hospice care. R1's family member (FM) visited R1 on 7/6/2024 and observed R1 was painful. FM requested staff to administer comfort medication injection to R1. The facility staff replied to FM that the facility staff were unable to administer comfort medications to R1.

On 7/17/2024, LPA interviewed ADM. ADM stated for the facility policy, only the facility nurse or licensed professionals can do the injection for residents. ADM stated for the hospice care residents, only the hospice agency nurse can do the injection.

LPA interviewed staff S2. S2 stated the facility staff are not allowed to administer comfort medications to R1 who is under hospice care, only R1's hospice care nurse can administer comfort medications injection to R1. S2 stated the facility notified R1's hospice care nurse to come to administer the comfort medication injection after FM's request.

LPA interviewed S3. S3 stated R1's hospice care nurse was at the facility on 7/6/2024 and 7/7/2024. S3 stated R1 was administered comfort medication injection on 7/6/2024 and 7/7/2024. S3 stated R1 was allowed to administer comfort medication every two hours as needed. S3 stated the hospice care nurse refused FM's request to administer comfort medication to R1 every two hours when R1 was calm and not painful.

LPA interviewed staff S4 and S5. Both stated R1's hospice care nurse was at the facility to administer comfort medications to R1 on 7/6/2024 and 7/7/2024. Both stated the facility staff are not allowed to administer comfort medication injection to R1.

Based on the review of R1 Appraisal Needs and Service Plan, staff to monitor R1's health condition, notify hospice care agency and family when changes in health condition. Comfort medications must be administered by R1's hospice care nurse.

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: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 26-AS-20240710154240

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: CAMPBELL VILLAGE	FACILITY NUMBER: 435294224
	VISIT DATE: 10/17/2024

NARRATIVE

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Based on the interviews and document reviewed, the facility staff are not allowed to administer comfort medications injection to R1. R1's hospice care nurse administered comfort medication injection for R1 on 7/6/2024 and 7/7/2024.

The Department has investigated the above allegation. Based on the investigation, document reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview conducted with MP. This report was provided to review and for signature. A copy of this report was provided to MP.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 7