435294287-6-10-2021-26-AS-KHOS-C3ZKBJ-20210615074536

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294287
Report Date: 06/08/2021
Date Signed: 06/10/2021 10:08:27 AM

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
06/03/2021 and conducted by Evaluator Steve Nguyen

COMPLAINT CONTROL NUMBER: 26-AS-20210603085916

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: 5	DATE:	06/08/2021
		UNANNOUNCED	TIME BEGAN:	11:41 AM
MET WITH:	Carlo Basilo		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Residents are restricted with pillows in beds.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Steve Nguyen and Marybeth Donovan conducted an unannounced 10-day complaint visit with Administrator Carlo Basilo.

On 06/03/2021, the Department received a complaint with the above allegation. On 06/08/2021, LPAs toured facility inside and out. LPAs interviewed the Administrator, two staff, Resident 1 (R1) and Resident 2 (R2).

Administrator stated that the pillows are not for restraint and that they are not restrictive but for safety and protective measures.

Both staff stated that the pillows are helpful in ensuring the safety of R1 and R2 and protects both R1 and R2 from injury.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve Nguyen	TELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

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-20210603085916

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: 06/08/2021

NARRATIVE

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R1 and R2 both stated that they are comfortable with the pillows and satisfied with the arrangements.

LPAs observed that the pillows placed on beds does not restrict movement of residents. Both residents are able to move freely in place and there is ample room for residents to move.

Medical records reviewed to obtain information on residents health status.

Based on LPAs observations, interviews conducted and records reviewed, the Department found that the above allegation 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 citation was issued during today's visit.

This report was discussed with Administrator, Carlo Basilio. A copy was provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve Nguyen	TELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC9099 (FAS) - (06/04)

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