435294345-7-1-2020-26-AS-RMAO-BRJ36C-20200714175806

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294345
Report Date: 06/29/2020
Date Signed: 07/01/2020 03:23:52 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
01/27/2020 and conducted by Evaluator Karen Taku

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200127111752

FACILITY NAME:	WESTMONT OF MORGAN HILL		FACILITY NUMBER:	435294345
ADMINISTRATOR:	STEVEN SILACCI		FACILITY TYPE:	740
ADDRESS:	1160 COCHRANE RD		TELEPHONE:	(408) 779-8490
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	112	CENSUS: 89	DATE:	06/29/2020
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Charmaine Verador		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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1. Facility staff caused injury to resident
2. Resident sustained bruising while in care

INVESTIGATION FINDINGS:

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On June 29, 2020, Licensing Program Analyst (LPA) Karen Taku conducted an unannounced Complaint Tele-visit to deliver investigation findings. Due to COVID19 preventative measures, the Department has suspended on-site visits. LPA spoke with Resident Services Director (RSD) Charmaine Verador.

On January 28, 2020, Community Care Licensing (CCL) received a complaint against Westmont of Morgan Hill alleging, staff caused injury to a resident and a resident sustained bruising while in care.

An initial investigation visit was conducted by LPAs Taku and LPM Manzano on January 28, 2020. During unannounced visit, LPA and LPM obtained a copy of staff and resident rosters, reviewed and obtained copies of resident records including, but not limited to, admission agreement, emergency contact information, physician’s report, assessments, appraisal needs and services plan, and outside health agency reports.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen Taku	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2020

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-20200127111752

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: WESTMONT OF MORGAN HILL	FACILITY NUMBER: 435294345
	VISIT DATE: 06/29/2020

NARRATIVE

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On March 3, 2020, LPA attempted to contact the Reporting Party (RP) for additional information regarding the above allegations. RP alleges, R1 was physically abused on 1/8/2020. RP observed a bruise on R1’s right cheek on 1/9/2020, which was not present during RP’s visit on 1/8/2020.

On 4/29/2020, LPA conducted an unannounced tele-visit to interview staff. (S1-S4)

Allegation #1 - Facility staff cause injury to resident
Allegation #2 - Resident sustained bruising while in care

Two out of four staff stated, they observed bruising on R1’s face during morning rounds on January 9, 2020. Bruise may have been caused by R1’s sleeping position, as R1 tends to sleep on right side with his face pressed against his shoulder. R1 was observed the night before; 1/8/2020, no incidents of discomfort or falls were reported. The hospice nurse also stated, the bruise may have been cause by R1’s sleeping position.

Two out of four staff stated, they’re not familiar with the incident that occurred on January 8, 2020 and agrees R1 is prone to self-inflicted bruising. R1 is known for hitting and punching the bed rails. As a result, bed rails have been padded to prevent and reduce self-injury.

Based on LPA’s review of R1’s medical and hospice records, R1 has a history of skin breakdown and self-inflicted injuries. R1’s skin is fragile and prone to bruising.

On April 22, 2020, LPA reviewed the facility’s monitoring logs, which indicated on 1/9/2020, discoloration on R1's right cheek was observed by staff. R1 continues to remove padding from bed rails, and staff continues to monitor R1's behavior.

On April 30, 2020, LPA interviewed R1’s Hospice nurse (HN). Per HN, bruising was observed by HN and a medical doctor, both agreed bruising was not due to physical abuse. HN also stated, R1’s bruising might be due to R1’s sleeping position and aggressive behavior. R1 tends to sleep on his right side with his hand bald in a fist, pressed against his face. R1 swings arms and legs when hitting and kicking while in bed. Padded bed rails were installed to prevent and reduce self-injury.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen Taku	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20200127111752

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: WESTMONT OF MORGAN HILL	FACILITY NUMBER: 435294345
	VISIT DATE: 06/29/2020

NARRATIVE

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On June 5, 2020, LPA attempted to interview R1, but due to R1’s medical condition LPA was unable to.

The Department has investigated the complaint allegations, and based on interviews conducted and review of records, although the allegations listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22

Exit interview conducted. A copy of this this report was emailed to Resident Services Director Charmaine Verado for signature.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen Taku	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2020

LIC9099 (FAS) - (06/04)

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