435294328-10-29-2021-26-AS-RMAO-C8DKLN-20211102080011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294328
Report Date: 10/29/2021
Date Signed: 10/29/2021 03:57:49 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
08/12/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20210812110952

FACILITY NAME:	VILLA FONTANA		FACILITY NUMBER:	435294328
ADMINISTRATOR:	DUEWEL, MA. FELICITAS V.		FACILITY TYPE:	740
ADDRESS:	5555 PROSPECT ROAD		TELEPHONE:	(408) 255-5555
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY:	104	CENSUS: 85	DATE:	10/29/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Marife Duewel		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff Physically abused a resident
Facility staff handled resident in a rough manner

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Steve Chang conducted a complaint investigation visit today to deliver investigation finding.

On 08/12/2021, the Department received the above complaint allegation that a resident was physically abused by facility staff.

On 08/13/2021, a complaint visit inspection was conducted. The following documents were obtained such as the facility staff and resident rosters, resident (R1) physician report, appraisal needs and service plan, admission agreement, centralized medication records, staff training, and medical and hospice records.

Page 1. See continuation page 2 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

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-20210812110952

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: VILLA FONTANA	FACILITY NUMBER: 435294328
	VISIT DATE: 10/29/2021

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

On 09/01/2021, the Department interviewed 6 facility staff (S1-S6), 3 residents (R1-R3) and R1’s family member. 6 Out of 6 staff stated R1 has sensitive and fragile skin that is easy to tear or cause bruises. 3 Out of 6 staff stated R1 has behavior of scratching, and flailing R1's arms, and maybe due the friction from changing R1’s clothes, blankets rubbing against R1's skin.

All 6 staff denied allegation that R1 was physically abused by staff and they do not know how or what was the cause of the R1's skin tear and bruises though they speculate that R1's skin tear and bruises may have been caused from scratching R1’s self. They placed pillows and paddings around R1 and bed rails to prevent R1 from injury.

All 6 staff stated that R1 has unpredictable behavior. When R1 gets agitated when ADLs are being provided, R1 will flails arms around and hits R1’s bed railings or chair arms. Staff also stated that R1 will made comments that staff are trying to poison R1 when being assisted with medication.

On 09/01/2021, the Department interviewed 3 residents, 2 Out 3 residents (R1-R2) did not speak or non-responsive while R3 loves living at the facility. R3 does not even feel scared or uncomfortable with staff.

On 09/08/2021, the Department interviewed R1’s family member (FM). FM stated that R1 has a frail skin. FM also witnessed R1 made comments about staff trying to hurt R1 or yell that R1 does not want to be touched. FM is aware that R1 is sometimes difficult to take care of because R1 will try to pull arms away when touched. R1. FM believes the bruises are caused from staff moving and adjusting R1 when the staff need to reposition R1. FM stated the staff places the pillow around R1 to prevent R1 from bruising, but there is not a lot of meat between R1's skin that caused R1's bruises. FM does not believe staff are intentionally hurting R1.

Page 2 of 3.

See continuation page 3 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 26-AS-20210812110952

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: VILLA FONTANA	FACILITY NUMBER: 435294328
	VISIT DATE: 10/29/2021

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

Based on the records reviewed, R1 has history of skin tears and R1 has behaviors of aggressive agitation and behavior of arm flailing.

The Department has investigated the above allegation. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegations are 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 was conducted with Administrator. This report was provided to ADM for signature. A copy of this report was emailed to ADM.

Page 3 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3