435294287-8-10-2020-26-AS-RMAO-BSJU86-20200816152058

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294287
Report Date: 08/10/2020
Date Signed: 08/10/2020 04:09:29 PM

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
06/10/2020 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200610102939

FACILITY NAME:	GOLDEN HILLS CARE HOME		FACILITY NUMBER:	435294287
ADMINISTRATOR:	BASILIO, CARLO		FACILITY TYPE:	740
ADDRESS:	2845 WESTBRANCH DRIVE		TELEPHONE:	(408) 528-1325
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY:	6	CENSUS: 3	DATE:	08/10/2020
		UNANNOUNCED	TIME BEGAN:	03:16 PM
MET WITH:	Carlo Basilio		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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1. Facility did not issue appropriate refund amount.
2. Staff is withholding resident's personal belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gladys Kuizon conducted a subsequent complaint tele-visit today to deliver investigation findings. Due to COVID-19 preventive measures, facility visits have been suspended. LPA met with Administrator Carlo Basilio.

On June 10, 2020, the Department received a complaint with the above allegations. On June 11, 2020, LPA interviewed the reporting party (RP) to obtain more information and on June 18, 2020, LPA conducted an initial complaint investigation visit to interview facility administrator (S1).

RP stated that the facility did not issue the appropriate refund after death of resident (R1) on May 11, 2020 and alleged that the facility withheld R1's personal belongings and continued to charge R1 rent for failure to remove all of R1's personal belongings from the facility.

Continued, see LIC 9099-C, page 2 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020

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 3

Control Number 26-AS-20200610102939

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: GOLDEN HILLS CARE HOME	FACILITY NUMBER: 435294287
	VISIT DATE: 08/10/2020

NARRATIVE

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LPA interviewed R1's spouse (F1), staff members (S2-S3), and residents (R2-R4). LPA also reviewed the facility's Admission Agreement, and email/text exchanges between facility, R1's representatives, and third parties.

The investigation revealed that R1 passed away at the facility on May 11, 2020. F1 was present bedside at time of passing. Upon leaving the facility that day, F1 stated that F1 will arrange for another day to pick up R1's belongings. On May 12, 2020, to assist F1, administrator, S1, contacted Veteran's Affairs (VA) to schedule a pick up of R1's hospital bed and lift. On May 13, 2020, VA responded and informed F1 and S1 that the bed and lift were purchased for R1 and are R1's personal properties, therefore, VA will not pick up. F1 offered S1 the items as a donation to the facility and S1 declined the donation at this time.

F1 attempted to find interested parties to pick up R1's heavy belongings: bed, lift, chair and wheelchair. F1 stated that due to COVID-19 restrictions, F1 did not pick up R1's other personal belongings (TV, DVD player, clothes, albums) to avoid multiple trips to the facility.

On May 18, 2020, F1 was unsuccessful in finding interested parties to pick up R1's heavy items. F1 offered the heavy items to S1 again. S1 refused the offer due to the facility not having the use for it. On May 20, 2020, F1 picked up all of R1's small personal belongings. On this day, an interested party was also found for R1's bed and lift. However, the interested party backed out when informed that the bed and lift are coming from a residential care facility for the elderly. At approximately 8:00 PM, another interested party wanted to pick up, however, the facility was unable to accommodate the pick up due to the time and short notice. As of May 22, 2020, the bed and lift remained at the facility but S1 agreed to stop the proration charges and accept F1's donation of the bed/lift due to the difficulty in finding an interested party.

Per page 4 of R1's Admission Agreement, "Upon the resident's death, the resident's representative is obligated to remove all personal properties from the unit/facility. The facility has the right to charge on a prorated daily basis until all personal properties, including beds, wheelchairs, walkers, commodes, oxygen tanks and other medical machines and instruments owned and/or leased for use by the resident, are removed from the premises."

Continued, see LIC 9099-C, page 3 of 3.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20200610102939

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: GOLDEN HILLS CARE HOME	FACILITY NUMBER: 435294287
	VISIT DATE: 08/10/2020

NARRATIVE

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On June 1, 2020, the facility issued a refund check to R1's responsible party, F1. The refund was calculated for the 30-day period of April 28 to May 28, 2020. Refund was given for the unused period of May 23 to May 28, 2020 (5 days) plus remaining balance of supplies and TV fund.

On July 14, 2020, R1's responsible party picked up all of R1's personal belongings from the facility.

2 out of 3 staff who were interviewed stated that the facility assisted R1's responsible party in packing and moving R1's personal belongings. 1 out of 3 staff who was interviewed was not working at the facility at the time period in question.

3 out of 3 residents who were interviewed stated they do not know R1 and have no information regarding when or how R1's personal belongings were removed from the facility.

This Department has investigated these allegations. Based on interviews conducted and records reviewed, the Department has found that these allegations are UNFOUNDED, meaning that the allegations are false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited. This report was discussed with and a copy emailed to Administrator for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020

LIC9099 (FAS) - (06/04)

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