435294328-10-18-2024-26-AS-KHOS-DABSQ6-20241023140412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294328
Report Date: 10/18/2024
Date Signed: 10/18/2024 04:59:58 PM

Substantiated

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
11/07/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20231107163604

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:	10/18/2024
		UNANNOUNCED	TIME BEGAN:	03:36 PM
MET WITH:	Marrife Duewel		TIME COMPLETED:	04:37 PM

ALLEGATION(S):

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A resident was inappropriately touched by another resident due to neglect and lack of supervision.

INVESTIGATION FINDINGS:

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

On 11/07/2023, the Department received a complaint with the allegation that a resident was inappropriately touched by another resident due to neglect and lack of supervision.

On 11/15/2023, the Department conducted an initial investigation visit. LPA interviewed ADM, 2 staff, and 1 resident.

LPA requested physician report, Appraisal Needs and Service Plan and care conference documents,

Continue on LIC9099-C. Page 1 of 3.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

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 4

Control Number 26-AS-20231107163604

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: VILLA FONTANA	FACILITY NUMBER: 435294328
	VISIT DATE: 10/18/2024

NARRATIVE

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A resident was inappropriately touched by another resident due to neglect and lack of supervision:
The allegation is that the facility neglected and lack of supervision resulting in a resident wandering to another resident's room and inappropriately touching another resident.

On 11/15/2023, LPA interviewed Executive Director (ED) Marrife Duewel. ED stated on 10/24/2023 around 2:00PM, resident R1 entered resident R2's room without permission. R1 exposed self to R2. and asked for oral sex. R1 inappropriately touched R2's breast and private areas. R2 asked R1 to stop. R1 stopped and left the room. ED stated he/she went to resident R2's room immediately after he/she received the report. ED stated he/she saw R1 walked down the hallway away from R2's room. ED stated no injury noted on resident R2 after the facility staff assessed R2.

ED stated after the incident, all staff were instructed to closely monitor R1's behavior and to ensure residents' safety. ED stated the facility notified R1's POA to come to the facility for a care conference on 10/24/2024, at 6:00PM. ED stated the facility notify R1's doctor the incident and to work on R1's medications.

ED stated after the incident, R1's doctor prescribed new medications for R1. R1 was provided a 1:1 private caregiver and R1 goes home with R1's family after dinner or R1' family to keep R1 company at night in the facility. ED stated the facility is working with R1's family to move R1 to another facility on the coming weekend.

LPA interviewed staff S1. S1 stated he/she sometimes saw R1 watching porn video in his/her room, and brought the concern to R1's care conference before this incident. S1 stated sometimes he/she saw R1 wandering in the hallway. S1 stated he/she asked caregivers to watch R1. S1 stated R1 did not have sexual incident before. S1 stated he/she knows some residents lock their door, but he/she know R2 does not lock the door.

LPA interviewed staff S2. S2 stated R1 and R2 are friends in the facility. S2 stated R1 and R2 sometimes have lunch or dinner together at the same table. S2 stated R1 and R1 did not have any inappropriately behavior before. S2 stated R1 usually go home with family on weekend or on holidays. S2 stated R1's care plan should be update to have more supervision and monitoring.

Continue on LIC9099-C. page 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20231107163604

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: VILLA FONTANA	FACILITY NUMBER: 435294328
	VISIT DATE: 10/18/2024

NARRATIVE

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LPA interviewed R2. R2 stated he/she does not want R1 to get punishment. R2 stated he/she wanted to participated the scheduled facility activity. The conversation was stopped.

Based on review of the law enforcement task report date 11/19/2023, the finding is R1 did enter R2's room and inappropriately touched R2's private areas.

Based on review of R1's physician report dated 6/23/2022, R1 has neurocognitive impairment, and has wandering behavior.

Based on review of R1's addendum to appraisal needs and service plan dated 10/02/2023, R1 had 2 incidents entering other resident's room on 10/15/23 and 10/17/2023, but the facility did not have effective action plan for it.

Based on the interview with staff S1, S1 observed R1 watching porn in R1's room and was naked in R1's room, and brought S1's concern in R1's care conference meeting, but the facility did not update R1's care plan.

Based on the interviews, and records reviewed, the facility lack of supervision resulting resident R1 wandering to resident R2's room and conducted inappropriately behavior and touched R2's private areas.

The Department has investigated the above allegation. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Citations were noted today. Please see LIC9099-D. Appeal right was provided. Exit interview was conducted with ED. A copy of the report was provide to ED.

Page 3 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20231107163604

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: VILLA FONTANA	FACILITY NUMBER: 435294328
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/25/2024 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director stated to submit a plan of correction by the POC due date to ensure residents to receive necessary care and supervision, and to provide staff training to prevent similar incident to happen. ED to submit the staff training log to CCL office.
	8 9 10 11 12 13 14	Based on interview and record review, The facility did not provide the necessary care and supervision to resident R1 to meet R1's care needs and leading to R1's wandering into R2's room and had inappropriately behavior and touched R2's private areas, which poses/posed an potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4