435294328-3-30-2021-26-AS-RMAO-BZYN7U-20210411101320

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294328
Report Date: 03/30/2021
Date Signed: 03/30/2021 05:38:17 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
10/27/2020 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20201027164831

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:	03/30/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Marife Duewel		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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1. Neglect/Lack of Care and Supervision which resulted in the deaths of residents.

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 Marife Duewel.

On 10/27/2020, the Department received a complaint allegation of neglect/lack of supervision which resulted in the deaths of residents.

On 10/29/2020, LPM Romeo Manzano and LPA Steve Chang, conducted a 10-day visit inspection/investigation of the allegation. LPM and LPA obtained residents' documents such as Physician's report, Appraisal Needs and Services Plan, Hospice reports, Infection Prevention of COVID-19 Plan, line listing, resident and staff rosters. and also conducted interviews with resident and facility staff.

Continued, see LIC 9099-C, page 2 of 3.

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: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

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-20201027164831

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: 03/30/2021

NARRATIVE

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On 11/12/2020, the Department conducted an unannounced facility visit. The facility had the appropriate COVID-19 signs posted. The facility's visitation policies and protocols were reviewed which are in compliance with COVID-19 requirement. The common areas were either cordoned off or the occupant status was drastically limited. The sanitation areas were readily available and properly supplied with sanitation materials. Both staffs and residents were wearing PPEs as required.

The Department interviewed 4 residents (R1- R4). 3 Of 4 residents claimed the facility has been adhering to COVID-19 mitigation procedures; the fourth resident was only able to provide a limited statement due to the memory issues.

On 11/12/2020 and 11/16/2020, the Department interviewed 7 facility staff (S1- S7). 7 Of 7 staff claimed the facility had been adhering to COVID-19 guidelines and directives. The Department interviewed 7 responsible parties of the 7 of 12 deceased residents (R5- R11). All family members were not physically able to conduct in-person visitations with their family members because the facility strictly followed the COVID-19 protocols. All the 8 Family members noted the facility staffs communicated with them via telephone, emails and mails regarding the facility's proactive measures to ensure the safety of residents and staffs during the COVID-19 pandemic. The facility utilized the assistance of Santa Clara County's Public Health Department and Kaiser to conduct COVID-19 testings.

The Department obtained certified copies of death certificates of residents who died between 07/04/2020 and 09/09/2020. Seven residents' deaths of the 12 deceased residents were due to or related to COVID-19.

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: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20201027164831

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: 03/30/2021

NARRATIVE

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The department has investigated the above allegation. Based on the investigation, 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 Administrator. A copy of this report was provided via e-mail for signature.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3