435294345-8-13-2023-26-AS-RMAO-CURKDV-20230816074918

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294345
Report Date: 08/11/2023
Date Signed: 08/13/2023 09:24:30 AM

Unsubstantiated

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
05/06/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20210506115407

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: 76	DATE:	08/11/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Jolie Higgins		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Steve Chang, Simi Rai and Manuel Monter conducted an unannounced investigation visit and met with Executive Director (ED) Jolie Higgins.

On 5/6/2021, the Department received a complaint with the above allegation. On 5/7/2021, an initial investigation visit was conducted.

During today's investigation, LPAs interviewed ED, Business Office Director (S1), and Med Tech (S2). LPAs requested resident R1's physician report and Appraisal Needs and Service Plan.

LPAs reviewed the incident report sent to CCL office dated 05/03/2021. R1 obtained bruise on his/her left forearm.

Continue on LIC9099-C, page 1 of 2.

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: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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 2

Control Number 26-AS-20210506115407

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: 08/11/2023

NARRATIVE

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On 05/07/2021, the Department interviewed the prior Executive Director (PED). PED stated during a transfer, R1 became excited and anxious, threw himself/herself onto the chair, and obtained bruises on R1's forearm. PED also stated R1 has resisted care before, and usually moves around during transfer.

On 8/11/2023, around 10:50AM, LPAs interviewed ED. ED stated ED knew R1 at another facility. ED stated R1 was easily get excited and moved around the two hands. ED stated R1 obtained bruise during transfer at another facility.

On 8/11/2023, around 11:30 AM, LPAs interviewed S1. S1 stated R1 needed two care givers to move/transfer, S1 stated R1 resisted during the care or transfer. S1 stated R1 moved two arms while transfer. LPAs interviewed S2. S2 stated R1 needed two caregivers to move/transfer. S2 stated it was tough to take care of R1. S2 stated R1 resisted the care provided by caregivers, sometimes R1 combated with the caregivers when caregivers provided the care or transfer. LPAs interviewed 2 caregivers (S3, S4), and both of them stated R1 resisted care and got excited when caregivers to provide the care and to transfer.

Based on the documents reviewed and interviews conducted, there is no evidence shows R1 obtained bruise due to staff's careless.

Based on record review of R1's physician report signed and dated 2/20/2019, R1 requires toileting assistance every 3-4 hours. The physician report also states R1 is a fall risk.

The Department has investigated the above allegation. Based on interviews, and record review, the department has found the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid, there is not a preponderance of evidence to show the alleged violations did or did not occur.

No citations were cited per California Code of Regulations, Title 22.

This report was reviewed with ED. A copy of the report was provided to ED.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2