435294345-10-29-2021-26-AS-RMAO-C9AMAK-20211201082625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294345
Report Date: 10/29/2021
Date Signed: 10/29/2021 12:50:42 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
11/14/2019 and conducted by Evaluator Christine Dolores

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20191114121715

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: 71	DATE:	10/29/2021
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Jolie Higgins		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Staff caused injury to resident
Staff pushed resident

INVESTIGATION FINDINGS:

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On 10/29/2021, Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced visit to deliver investigation findings. LPA met with Executive Director, Jolie Higgins.

On 11/14/2019, Community Care Licensing Division (CCLD) – Adult and Senior Care (ASC) received a complaint against the facility, alleging a facility staff caused injury to a resident and the resident sustained bruising while in care. Based on investigation, on 11/10/2019, R1 yelled out in pain due to discomfort while staff was assisting R1 with repositioning, which resulted in bruising on R1’s left chest wall.

On 11/21/2019, LPAs Karen Taku and Natkarn Shugan, conducted an unannounced initial complaint investigation visit and met with Resident Services Directors (RSDs) Diane Martinez (S1) and Charmanie Verador (S2).

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

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-20191114121715

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: 10/29/2021

NARRATIVE

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On 01/28/2020, (LPA) Karen Taku and Licensing Program Manager (LPM) Romeo Manzano conducted a subsequent visit, and interviewed the Executive Director, Resident Services Director in Memory Care, and Assisted Living Director, and 5 direct staff and obtained copies from R1's facility records such as Physician's report, Incident reports, appraisal needs and services and centrally stored medication log.

On 10/19/2020, LPAs Karen Taku and Grace Davis conducted an unannounced subsequent Complaint Investigation Tele-visit. During visit, LPAs requested resident records and interviewed staff.

LPA interviewed 8 facility staff. 4 Out of 8 staff (S1-S4) are not familiar with R1's large mass on R1's left breast while 4 staff (S5 -S8), who stated that have observed R1's swollen left breast. Staff denied allegations of abuse and no incidents occurred prior to the observation of the mass. S5 stated S5's observed R1's bump on R1's chest and two hours later, the bump had grown in size, which resulted in emergency services being called (911) and R1 being transferred outside of the community. S6 stated S6 was aware of R1's swollen breast that resulted into R1's hospitalization. S6 stated that there were no incidents of abuse reported to S6 by staff, nor R1 was physically abused during R1's residency in the memory care.

Based on review of R1's Internal Incident Report on 11/10/2019, S5 was notified by staff that R1 had a large mass on left breast which grew in size in about 2 hours resident complained of severe pain. R1 was sent out to be evaluated through 911 call. R1's primary care physician (PCP) was notified on the same day and R1's responsible parties. R1's PCP was also notified on same day that R1's left hand was still and pushes against R1's breast which causes bruising and there was also a tight hard mass on the upper part of R1's breast.

Based on review of R1's Med Tech to Med Tech Communication Log between 10/9/2019 to 11/10/2019, staff noted on the following days R1's incidents: 10/9/2019, R1 was agitated wherein R1's responsible party was notified; 10/11/2019, R1 had an aggressive behavior, 10/18/2019; R1 noted to have skin discoloration on left breast and side area with no complaint of pain or discomfort; 11/1/2019 R1 complained of pain and discomfort on bottom wherein refused pain medication; 11/2/2019 R1 had a bruise under left arm and provided pain medication and on 11/10/2019, R1's swollen left breast with severe pain noted.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20191114121715

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: 10/29/2021

NARRATIVE

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On 11/21/2019, LPA Shugan interviewed the Resident Service Director (S9) who stated awareness of R1's bruise, hard mass and complaints of severe pain but no mention of staff having caused the injury to resident. Staff denied allegation of abuse wherein R1 was pushed by staff resulted in R1 sustaining a left breast bruise and swelling. On 04/22/2021, S9 stated that there was no medical records findings received from the hospital.

R1 was not interviewed. R1 did not return to the facility after R1's hospitalization in 11/10/2019 and no longer resides at the facility.

The department has investigated the above allegations. Based on the record review and staff interviews the Department has 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.

Exit interview conducted with Executive Director, Jolie Higgins. A copy of this report was provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC9099 (FAS) - (06/04)

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