435294328-4-7-2021-26-AS-RMAO-BZYN9S-20210411101623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294328
Report Date: 03/30/2021
Date Signed: 04/07/2021 04:57:42 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:	03/30/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Marife Duewel		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not assist residents with feeding.
Staff not keeping residents safe from other residents.
Staff are not familiar with Emergency Disaster Plan.

INVESTIGATION FINDINGS:

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This report has been amended to reflect new investigative findings from 3/30/2021 report. On 4/7/2021 at 10:30AM, 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 4

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: 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

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-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: 03/30/2021

NARRATIVE

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Staff did not assist residents with feeding:

On 11/25/2020, LPA interviewed ADM regarding a complaint wherein a resident (R1) was not assisted with meals about a year ago. ADM stated that the incident happened in the dining room. ADM stated that caregivers were assisting more than one residents at one time. ADM stated that R1 was assisted with meals but it might have looked like that R1 was not being fed because staff were taking turns to fed other residents. ADM stated the facility started to provide the meals at resident room and helped the resident at resident room if the residents needed help for eating since the COVID-19 pandemic March 2020.

Staff not keeping residents safe from other residents:

On 11/20/2020, LPA interviewed ADM regarding resident (R4) hitting another resident. ADM stated that facility was aware of R4's aggressive behavior which happened two years ago. ADM stated that R4's aggressive behavior has been addressed at that time. ADM stated that the facility put all their effort to protect residents for potential risk or injury towards other residents. ADM stated R4 did not hit other residents. ADM stated that R4's family was informed about R4's behavior. ADM stated that R4 was transferred at another facility that can meet R4's need.

Continued, see LIC 9099-C, page 3 of 4

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 4

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: 03/30/2021

NARRATIVE

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Staff are not familiar with Emergency Disaster Plan:

On 11/20/2020, LPA interviewed ADM about facility staff's familiarity of facility Emergency Disaster Plan. A resident received a text notification regarding fire evacuation in the area. This resident was concerned and went to the front desk and asked the staff (S4) to inquire if the facility received an evacuation order due wildfires. Alleged that staff (S4) was not aware of fire evacuation order, and when asked about facility's Emergency Disaster on Fire, S4 did not know. S4 was not interviewed as S4 is no longer employed at the facility.

ADM narrated the facility Emergency Disaster Plan, and described her team members' roles in the Emergency Disaster Plan. ADM stated the facility has the drill every quarter. ADM provided the facility emergency plan detail and the drill reports to LPA.

LPA interviewed staff (S5, S6, S7, S8 and S9) about the emergency disaster plan. All staff narrated and described what they need to do during the emergency. Staff were able to respond to questions about what to do during emergency situations in the facility. All staff received training on emergency disaster drills.

Continued, see LIC 9099-C, page 4 of 4

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 4

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: 03/30/2021

NARRATIVE

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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 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 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: 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)

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