435294224-7-11-2023-26-AS-RMAO-CU4N68-20230726101040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294224
Report Date: 07/11/2023
Date Signed: 07/11/2023 11:16:17 AM

Unfounded

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
08/07/2020 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200807164928

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: 63	DATE:	07/11/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator, Geralyn De Campo		TIME COMPLETED:	11:20 PM

ALLEGATION(S):

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Staff hit and punched resident resulting in bruising

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai and Licensing Program Manager (LPM) Romeo Manzano conducted an investigation on the above allegation and met with Administrator (ADM) Geralyn De Campo.

Based on interviews and records review, on 7/13/2020, R1 had a fall. As a result of R1's fall, R1 sustained injuries consistent with fall. R1 was assessed by ADM after the incident.

On 07/13/2020 at 2:45PM, Staff (S1) was about to sit R1 in the chair but R1 was unbalanced and fell to the floor, and hit his/her face to the floor. R1 sustained skin abrasion and discolaration on his/her nose bridge.

Continuation on LIC 9099-C, Page 1 out of 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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-20200807164928

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: 07/11/2023

NARRATIVE

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Page 2 out of 2.
On 7/31/2020 at 2:30PM, one of R1's children visited R1 and observed R1's injuries. The staff was not able to provide details on what happened to R1. R1's child accused the facility of physical abuse by not disclosing the information to him/her. He/She summoned 911 and law enforcement and they conducted investigation. ADM stated that R1's public guardian was informed about the incident.

On 07/11/2023, LPA and LPM obtained and reviewed the following documents of R1, a copy of LIC624, a copy of SOC341, LIC601, LIC602A, a copy of care conference, R1's photo, and memory care Med-Tech endorsement dated 7/13/2020. LPA conducted an interview with Administrator (ADM) De Ocampo. ADM stated could not remember the exact details of the incident but what she could remember was that resident (R1) was out of balance when R1 was trying to sit down on a chair. ADM stated that the R1's nurse practitioner from Care More and public guardian were notified. ADM stated that R1's child was not contacted regarding R1's fall. ADM stated that R1's child came to visit and found R1's bruise on nose wherein he/she called 911 and law enforcement to report physical abuse against the facility. ADM stated that there were no reports or incidents that R1 was being physically abused by staff.

On 07/11/2023, LPA conducted interviewed staff (S1), S1 stated that he/she called the public guardian and care home nurse regarding R1's incident. S1 stated S2 called S1 to report that S2 saw R1 about to sit down on the chair but missed sitting on the chair and fell but it was too late then to intervene. S1 stated that first aid was applied and R1 did not complain or unable to verbalize of any pain due to neuro-cognitive disorder. S1 stated that there were no reports of staff physically hitting or punching R1. S2 no longer employed by the facility.

Based on overall investigation on physical abuse of R1, interviews with staff and records review revealed that R1 had a fall resulted an injury. There were no evidence of physical abuse.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.
No deficiencies cited, exit interview conducted with Administrator, Geralyn De Campo and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC9099 (FAS) - (06/04)

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