435294328-10-18-2023-26-AS-RMAO-CYWLCG-20231227073819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294328
Report Date: 10/18/2023
Date Signed: 10/18/2023 04:55:37 PM

Unsubstantiated

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
12/27/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20211227120322

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: 86	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	10:39 AM
MET WITH:	Marife Duewel		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Resident sustained unexplained burn(s) while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Marife Duewei.

On 12/27/2021, the Department received a complaint with the allegation that Resident sustained unexplained burn(s) while in care.

On 12/30/2021, the initial investigation visit was conducted, LPA interviewed ED and 3 staff (S1 - S3). Resident physician report and Apprasial Needs and Service Plan were obtained.

Continue on LIC9099-C. Page 1 of 2.

Unsubstantiated

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: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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 2

Control Number 26-AS-20211227120322

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: 10/18/2023

NARRATIVE

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Resident sustained unexplained burn(s) while in care:
On 12/30/2021, LPA interviewed Executive Director (ED) Marife Duewel. ED stated resident R1 usually had shower around 4:00PM - 8:00PM, twice per week, but R1 did not have shower on 12/24/2021. ED stated R1 needed 2 caregivers to help with the shower. ED stated R1's right hand was found blisters before breakfast on 12/25/2021. R1 was sent to hospital after assessment. ED stated R1's right hand was paralyzed, was unable to stand up by self, and electrical blankets were not allowed in the facility. ED stated no hot coffee spilled on R1's right hand.

On the same day, LPA interviewed 3 staff (S1 - S3). 3 out of 3 stated R1 was normal before breakfast on 12/25/2021 and on the previous day 12/24/2021, there were no incidents such as hot water or hot coffee spilled on R1's right hand. S2 stated it might be the issue of infection or allergy on R1's right hand.

On 12/30/2021, LPA toured R1's room, there were no electric blankets observed. LPA measured the temperature of water of R1's bathroom, and it was 107-degree Fahrenheit. LPA measured the hot water temperature of a common bathroom, and it was 119-degree Fahrenheit.

On 1/31/2023, LPA interviewed staff S4. S4 stated he/she was on duty on 12/25/2021 morning shift, and found R1's right hand had blisters, but not on the whole right arm, before breakfast in the dining room. S4 stated there was no hot water or hot coffee spilled on R1's right hand. S4 stated he/she did not know that R1's right hand's blisters were due to burn, infection, or allergy.

Based on reviewing of R1's medical documents, R1's right hand was paralyzed, R1 needed help for showering, R1 was non-ambulatory, and R1 needed help to transfer.

The department has investigated the above allegation. Based on the observations, records reviewed, and interviews conducted, the Department found that the above allegation is 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 allegations did or did not occur.

No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ED. A copy of this report was provided to ED.
Page 2 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2