435294328-4-7-2021-26-AS-RMAO-BZYN9R-20210411101623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294328
Report Date: 04/07/2021
Date Signed: 04/07/2021 04:56:45 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
10/23/2020 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20201023142256

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:	04/07/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Marife Duewel		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Staff providing false information about resident's health.
Facility had molds that exacerbated resident's health.
Residents had an outdoor physical activities on days with poor air quality.
Facility food menu does not have options for those on special diets.
Foods served in the facility does not meet the recommended dietary allowance.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted a complaint tele-visit today to deliver investigation findings. Due to COVID-19 preventive measures, facility visits have been suspended. LPA met with administrator (ADM) Marife Duewel.

On 10/23/2020, the Department received a complaint about the above allegations against the facility. An initial complaint investigation visit was conducted on 10/29/2020. The facility was toured inside and out. Staff and residents were interviewed. Resident/staff rosters, facility floor plan, mitigation plan, infection prevention plan, facility food menu, LIC610E, and LIC500 were obtained . On 11/20/2020, 11/25/2020, LPA interviewed several staff, residents, and ADM.

Continued, see LIC 9099-C, 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: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

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-20201023142256

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: 04/07/2021

NARRATIVE

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Staff provided false information about a resident's health:
On 11/20/2020, LPA interviewed administrator (ADM). ADM stated that on 3/8/2020, a staff (S1) inadvertently provided health information of resident (R2) to resident (R3's) family member. LPA interviewed staff (S1). S1 stated that R3's file was pulled incorrectly. R3's family was called and informed that R3 was ill instead of R2's family. R3's family became very worried about R3. R3 became very upset with the mixed up. R3 was not ill nor had health issues. ADM and S1 stated that the facility did not provide false information about a resident's health but just called the wrong family member.

Facility had molds that exacerbated resident's health conditions:
On 11/20/2020, LPA interviewed third party contractor (C1) and ADM. C1 stated that during contraction there were no evidence of molds found in the facility and the noise coming from the construction.

During investigation, ADM provided a copy of facility mold inspection report dated 11/25/2020 that states, "No visible suspect mold growth or elevated moisture found at the time of inspection." ADM stated that R3's room was inspected including bathroom. ADM stated that there were no molds found in R3's bedroom and bathroom. ADM stated that staff were cleaning R3's room once a week or as needed. ADM stated that the facility was being cleaned such as but not limited to vacuuming carpets, wiping tables, cleaning bathroom and bath tubs. ADM stated that there was no medical records to indicate that R3's heath condition was exacerbated by molds or by the noise coming from the construction. ADM stated that R3 did not report any health concerns to the facility.

Continued, see LIC 9099-C, 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: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20201023142256

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: 04/07/2021

NARRATIVE

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Residents had an outdoor physical activities on days with poor air quality:
On 11/20/2020, LPA interviewed the facility Activity Director (S10) and the Activity Assistant (S11). Staff S10 and S11 denied the allegation that activities were conducted outdoor despite poor air quality. S10 and S11 stated that before an outdoor activities, they had to check the air quality before the outdoor activity. If the air quality was not good, then the outdoor activity either moved to indoor or canceled. LPA interviewed 3 residents (R2, R4 and R8). All residents stated that they had outdoor activity sometime in July and August 2020 wherein the air quality was good and also stated the facility conducts indoor activity when air quality was bad.

Facility food menu does not have options for those on special diets:
Foods served in the facility does not meet the recommended dietary allowance
On 11/20/2020, LPA interviewed ADM and staff. ADM and dietary manager and assistant dietary manager (S12 and S13) stated that the facility does not have special diets written on the facility menu, however, the facility is able to accommodate residents' special request outside from the facility menu and the facility adheres to residents with special or modified diet order. S12 and S13 stated that they modify food menu when needed, and residents were free to request changes on the food menu.

On 11/25/2020, LPA interviewed 5 residents (R8- R12), 5 of 5 residents stated the facility provides a modified diet and food options outside the facility menu. All 5 residents did not have any complaints about the facility menu or food being served. On 10/29/20, LPA observed meals during dinner time, the food served comprised of the following mixed vegetables, potatoes, bread and chicken, soup, a glass of water, cup of coffee, banana, green salad and a dessert.

The department has investigated the above allegations. Based on the investigation, observations, 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 deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with Administrator. A copy of this report was provided via email for signature.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

LIC9099 (FAS) - (06/04)

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