<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294340
Report Date: 05/18/2023
Date Signed: 05/18/2023 05:43:02 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
05/10/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230510121329
FACILITY NAME:MOLDAW FAMILY RESIDENCES AT 899 CHARLESTONFACILITY NUMBER:
435294340
ADMINISTRATOR:ELYSE GERSONFACILITY TYPE:
741
ADDRESS:899 EAST CHARLESTON ROADTELEPHONE:
(650) 433-3600
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:270CENSUS: 160DATE:
05/18/2023
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Karen LernerTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handles residents in a rough manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Marrufo conducted an unannounced complaint investigation visit and met with Karen Lerner. On 05/10/2023, the Department received the complaint allegations and on 05/12/2023, LPA Marrufo conducted an initial complaint investigation visit.

During visit on 05/12/2023, LPA Marrufo obtained copies of the following documents: resident R1 and R2’s Physician’s Report and Appraisal/Needs and Services Plan, Internal Incident Reports from staff S1-S5, Resident Roster, and Staff Roster. LPA Marrufo conducted interviews with staff S2, S6-S7, and attempted interviews with residents R1 and R2. LPA observed R1 and R2 during visit and conducted additional resident interviews.

S1’s Internal Incident Report states that during the beginning of S1’s PM shift, S1 was doing rounds with S2 and S3. S1 stated that the residents were lying on top of their comforters, which made it hard for the staff to turn them during rounds. See LIC9099-C for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
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 5
Control Number 26-AS-20230510121329
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: MOLDAW FAMILY RESIDENCES AT 899 CHARLESTON
FACILITY NUMBER: 435294340
VISIT DATE: 05/18/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
S2’s Internal Incident Report states while making rounds with S1, S1 began to pull R1’s comforter back while R1 was still on the bed. S2 described the way S1 pulled the comforter as “very rough.” S2 stated that S1 and S2 then went to R2’s bedroom. There, S1 began pulling on R2’s jeans while they were still buttoned on R2. S2 stated to have observed R2 to look as if R2 was in pain while S1 was pulling on R2’s jeans. S2 then told S1 that that was not the correct way to pull down the jeans but S1 ignored S2 and said the resident was fine. S2 then stayed with R2 to check on the resident and then reported the incidents to S2’s supervisor, S4.

S3’s Internal Incident Report states that S1 grabbed R1’s blanket and tossed R1 over and yanked on R1’s pants to take them off. S3 states S1 then went to R2’s room and yanked on R2’s yellow blanket. Then, S1 yanked on R2’s pants without unbuttoning R2’s pants. S3 stated S2 told S1 to unbutton the pants because S1 was hurting R2.

S4’s Internal Report states that S4 observed S1 pulling on R2’s jeans.

During interviews, S1 stated that R1 and R2 were not properly placed on their draw sheets by the morning shift staff, so S1 did not attempt to turn over R1 and R2. S1 stated to have not pulled on R1 or R2's pants and that S2 already had denim pants pulled down R2's waist when S1 arrived.

During interviews, S2 and S3 stated to have observed S1 pull on the blankets that R1 and R2 were resting on to turn them over. S2 and S3 stated to have observed S1 pulling on R1’s and R2’s pants to check them during rounds. S2 and S3 stated that S1 pulled on R2’s pants while they were still buttoned.

Based on records review and interviews, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Karen Lerner and a copy of the report and appela rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20230510121329
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: MOLDAW FAMILY RESIDENCES AT 899 CHARLESTON
FACILITY NUMBER: 435294340
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2023
Section Cited
CCR
87468.1(a)(3)
1
2
3
4
5
6
7
87468.1(a)(3) Personal Rights: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding
1
2
3
4
5
6
7
Licensee agrees to develop a plan to conduct in-service training for all direct care staff on proper protocols for turning residents in bed and checking on their soiled diapers and submit the plan to CCL by POC date. Once the in-service trainings are completed, Licensee agrees to submit copies of the
8
9
10
11
12
13
14
residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Licensee did not ensure that staff S1 did not handle residents R1 and R2 in a rough manner by pulling on their blankets and pants, which poses an immediate safety risk to residents in care.
8
9
10
11
12
13
14
in-service training logs to CCL. The logs should include names of staff trained, dates of training, training topic, and name and qualification of trainers.
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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
05/10/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230510121329

FACILITY NAME:MOLDAW FAMILY RESIDENCES AT 899 CHARLESTONFACILITY NUMBER:
435294340
ADMINISTRATOR:ELYSE GERSONFACILITY TYPE:
741
ADDRESS:899 EAST CHARLESTON ROADTELEPHONE:
(650) 433-3600
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:270CENSUS: 160DATE:
05/18/2023
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Karen LernerTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained bruises while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Marrufo observed residents R1 and R2. LPA Marrufo observed that R1 had bruising on both of R1’s knees. LPA Marrufo observed R1 to wear cushioned boots that wrapped around R1’s knees to prevent R1 from hitting R1’s legs against R1’s wheelchair.

LPA Marrufo observed R2 was wearing pants and a long sleeve shirt during visit. LPA observed R2 for bruising on the areas of R2’s skin that were visible but did not find any bruising. LPA observed R2 had redness on R2’s tailbone area.

During interview, staff S2 stated that R1 had bruising, but S2 was not sure if S1 caused the bruising. S2 stated that R2 had bruising on R2’s lower back.

See LIC9099-C for more information. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20230510121329
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: MOLDAW FAMILY RESIDENCES AT 899 CHARLESTON
FACILITY NUMBER: 435294340
VISIT DATE: 05/18/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
S3 stated during interview to have not observed any bruising on R1 or R2.

S5’s written report from 05/09/2023 states that there is a “noted discoloration on left lower posterior leg” of R1. During interview, S5 stated to have not observed S1 when S1 was conducting rounds and checking on S1 and S2.


Based on information from interviews conducted with staff, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore the allegation is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Karen Lerner and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5