435294328-10-18-2024-26-AS-KHOS-DABSZE-20241023141900

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294328
Report Date: 10/18/2024
Date Signed: 10/18/2024 05:03:09 PM

Unfounded

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
03/17/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20230317143144

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:	02:50 PM
MET WITH:	Marife Duewel		TIME COMPLETED:	04:42 PM

ALLEGATION(S):

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Facility did not have non-perishable foods for a minimum of a week.
Facility staff are not properly supervising residents when administering medications.
Residents centrally stored medications are expired.

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 Duewel.

On 3/17/2023, the Department received a complaint with the above allegations.

On 3/22/2023, the Department conducted an initial investigation visit. LPA interviewed ADM, 11 staff (S1 - S11), and 6 residents (R1 - R6). LPA obtained roster of residents, and requested 6 residents medical document.

On 4/7/2023, LPA conducted an investigation visit and interviewed 3 residents.

Continue on LIC9099-C. Page 1 of 5.

Unfounded

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 8

Control Number 26-AS-20230317143144

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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Facility did not have non-perishable foods for a minimum of a week:
The allegation is that the facility did not have non perishable food for a minimum of a week for residents during the power outage period on 3/14/2023.

On 3/22/2023, LPA interviewed Executive Director (ED) Marife Duewel. ED stated the facility had a power outrage on 3/14/2023 and 3/15/2023. ED stated the facility has generator and some small gas stoves, so only had a minimum impact for the food service to residents. ED stated the facility usually has 1-2 weeks non perishable food supplies in stock. ED stated usually non perishable food supplies are delivered on Wednesday every week. ED stated on 3/15/2023, Wednesday, the food delivering company was unable to deliver the non perishable food property due to the facility power outage but the facility still had over than one week non perishable food supplies in stock. ED stated the facility provided enough food for residents during the power outage period. ED stated he/she did not receive any complaint from residents regarding the food service during the power outage period.

LPA toured with ED to check the food supplies. LPA observed perishable food supplies are sufficient for a minimum of 2 days, and non perishable food supplies are sufficient for a minimum of 7 days.

LPA interviewed Dietary Manager (DM). DM stated the facility has power outage emergency food menu if power outage occurs. DM stated the facility provided sufficient food supplies to residents during the power outage period on 3/14/2023 and 3/15/2023.

LPA interviewed a cook (C1). C1 stated he/she cooked on 3/14/2023 and 3/15/2023. C1 stated the facility provided sufficient food supplies for residents during the power outrage period. LPA interviewed a kitchen server (K1). K1 stated there were 2 cooks cooked food and 5 servers delivered the food to residents during the power outrage period. K1 stated residents were well fed during the power outrage period.

LPA interviewed 5 residents. 5 out 5 residents stated they did not have any complaint against the facility during the facility power outrage period.

Based on the interviews and observation, no evidence to indicate the facility did not have no perishable food supplies for a minimum of a week during the facility power outrage period.
Continue on LIC909-C. page 2 of 5.

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 8

Control Number 26-AS-20230317143144

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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Facility staff are not properly supervising residents when administering medications:
The allegation is that Med Techs left medications in resident rooms unattended.

On 3/22/2024, LPA interviewed ED. ED stated Med Techs deliver mediation to residents and assist residents to administer medications. ED stated Med Techs take the medications with them when residents refuse medications. ED stated Med Techs are not allowed to leave medications in resident rooms unattended

LPA interviewed 2 Med Techs. Both stated they deliver medications to residents and assist to administer medications to residents. Both stated they take the medications out from the resident rooms and discard the medications if residents refuse the medications 3 times. Both denied they put the medications in resident room unattended.

LPA interviewed 5 residents. 5 out of 5 residents stated Med Techs never left the medications in their room and left the rooms. LPA toured and checked 5 resident rooms, and did not observe any medications left in the resident rooms.

On 4/7/2023, LPA interviewed 2 residents. 2 out 2 residents stated Med Techs did not leave the medications in the room unattended. LPA toured and checked 2 resident rooms and did not observe medications left in resident rooms unattended.

Based on the interviews and observation, there is no evidence to indicate facility staff are not properly supervising residents when administering medications.

Residents centrally stored medications are expired:
The allegation is that the centrally stored medications delivered to residents are expired.

On 3/22/2024, LPA checked the medications of medications carts. LPA randomly picked up 10 medications to check the expiration, LPA did not find any expired medications in medications carts. LPA checked two medication rooms, LPA randomly picked up 10 medications to check the expiration, and did not find any expired medications.
Continue on LIC9099-C. page 3 of 5.

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 8

Control Number 26-AS-20230317143144

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 Assist Living Unit Director (ALD). ALD stated Med Techs check the medications for expiration. Med Techs put the expired medications in the "expired medication box" in the corner of the medication room, and document it.

ALD stated the Director of Memory Care, Director of Assist Living, and Coordinator of Memory Care/Assist Living review the document and medications to approve to dispose the expired medications. ALD stated the approved expired medications are moved from the expired medication box to Medication destruction room. ALD stated only Director of Memory Care and Director of Assist Living have the key of the expired medication destruction room.

LPA observed the expired medication box was locked. Staff S6 toured LPA to the medication destruction room. LPA observed the room was locked and the big box inside the room was locked.

LPA interviewed Memory Care Director (MCD). MCD stated every 3 months, the expired medication destruction company comes to pick up the expired medications.

Based on the observation and interview, the facility has standard procedure to process the expired medication and LPA did not find any expired medications after inspection the medication carts and medication rooms.

Residents centrally stored medication records are incomplete:
The allegation is that the residents centrally stored medication records are incomplete.

On 3/22/2023, LPA interviewed Executive Director (ED). ED stated Med Techs are trained and instructed to document centrally stored medication records and MAR. ED stated the Directors of Memory Care Unit, Director of Assist Living Unit and facility nurses also monitor on that.

LPA randomly picked up 5 residents centrally stored medication records and medications to check. 5 Out of 5 residents medications did not have mismatch , incorrect, or inaccuracy.

Page 4 of 5.

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: 4 of 8

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
03/17/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20230317143144

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: 77	DATE:	10/18/2024
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Marife Duewel		TIME COMPLETED:	04:42 PM

ALLEGATION(S):

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Residents were administered insulin injection by non appropriately skilled professional.
Residents centrally stored medication records are incomplete.

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 Marife Duewel.

On 3/17/2023, the Department received a complaint with the above allegations. .

On 3/22/2023, the Department conducted an initial investigation visit. LPA interviewed ADM, 11 staff (S1 - S11), and 6 residents (R1 - R6). LPA obtained roster of residents, and requested 6 residents medical document.

On 4/7/2023, LPA conducted an investigation visit and interviewed 3 residents.

Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

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: 5 of 8

Control Number 26-AS-20230317143144

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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Residents were administered insulin injection by non appropriately skilled professional:
It has been alleged that residents were administered insulin injection by staff S1 who has no nurse license.

On 3/22/2023, LPA interviewed ED. ED stated the facility always has at least 1 nurse at facility, sometimes more than 1 nurses at the facility. ED stated if nurse calls sick, the facility finds other facility nurse to cover or other nurse from other agencies to cover.

LPA interviewed Resident Care Coordinator S1. S1 stated he/she received nursing training but does not have nurse license. S1 stated he/she does not administer insulin injection to residents. S1 stated he/she supervises caregivers and provides help for resident medications and provides help for arrange doctor appointment for residents. S1 stated the facility has 1 LVN for the AM shift and 1 RN for the PM shift to administer insulin injection for residents. S1 sated the facility has another one RN and two LVNs as part time staff to administer insulin injection for residents. S1 stated on 3/17/2023, he/she was on duty but he/she does not know who was the nurse to administer insulin injection for residents that day.

LPA interviewed Health and Wellness Director S2. S2 stated he/she is a LVN. S2 stated he/she works Monday to Friday from 7:30AM to 3:30PM. S2 stated he/she administers insulin injection for residents. S2 stated on 3/17/2023, he/she was off and did not know who to administer insulin injection for residents that day. S2 stated the facility has 2 RNs and 1 LVN work for the PM shift to administer insulin injection for residents, and one LVN works for the weekend to administer insulin injection for residents.

LPA interviewed 6 residents. R1 does not have insulin injection. R2 was unable to remember if he/she has insulin injection. R3 was unable to remembered the names of the nurses who administered insulin injection. R3 remembered a male staff who is not a nurse helped to administer insulin injection. R3 was unable to confirm that the male staff did the injection or the male staff just helped him and R3 did the injection self. R4 remembered the names of the nurses administered insulin injection and S1 also helped to administer insulin injection. R4 was unable to confirm that S1 did the injection or S1 helped R4 and R4 did the injection self. R5 was unable to remember the names of the staff who administered insulin injection. R6 refused to be interviewed.

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: 6 of 8

Control Number 26-AS-20230317143144

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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Based on the interviews, the facility sometimes has staff without nurse license to help residents for insulin injection. There is no evidence to indicate staff without nurse license conduct the insulin injection to residents.

Residents centrally stored medication records are incomplete:
The allegation is that the residents centrally stored medication records are incomplete.

On 3/22/2023, LPA interviewed Executive Director (ED). ED stated Med Techs are trained and instructed to document centrally stored medication records and MAR. ED stated the Directors of Memory Care Unit, Director of Assist Living Unit and facility nurses also monitor on that.

LPA randomly picked up 5 residents centrally stored medication records and medications to check. 5 Out of 5 residents medications did not have mismatch , incorrect, or inaccuracy.

Based on the interview and record reviewed, there is no evidence to indicate residents centrally stored medication records are incorrect or incomplete.

Based on documents reviewed, and interviews conducted, the Department found that the above allegations 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 citations noted for today’s visit. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of this report was provided 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: 7 of 8

Control Number 26-AS-20230317143144

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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The Department has investigated the above allegations. Based on the investigation, and interviews conducted, the Department found that the above allegation is 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 conducted with Executive Director (ED). This report was provided to review and for signature. A copy of this report was provided to ED.

Page 5 of 5.

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: 8 of 8