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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 440708909
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:29:00 PM

Unsubstantiated


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
09/26/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230926140323
FACILITY NAME:WESLEY HOUSE IIIFACILITY NUMBER:
440708909
ADMINISTRATOR:LEON, JANETFACILITY TYPE:
740
ADDRESS:123 LA SELVA DRIVETELEPHONE:
(831) 685-0646
CITY:LA SELVA BEACHSTATE: CAZIP CODE:
95076
CAPACITY:6CENSUS: 4DATE:
02/27/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Janet LeonTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff violated resident's personal rights
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Janet Leon, Administrator.

On 09/26/2023, the facility received a complaint with the above allegation. On 10/05/2023, the Department conducted an initial complaint investigation visit and conducted an additional visit on 12/07/2023. LPA Marrufo interviewed facility staff and Administrator, resident R1's Family Members F1 and F2, and R1's Hospice Nurse Case Manager N1. LPA Marrufo obtained copies of resident and facility records.

Resident R1’s Admission Agreement was signed 08/09/2023 by resident’s Responsible Party. The Admission Agreement Visitation Policy states, “The facility is open for visiting from 10 AM to 4 PM.

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: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
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 6
Control Number 26-AS-20230926140323
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: WESLEY HOUSE III
FACILITY NUMBER: 440708909
VISIT DATE: 02/27/2024
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
Additional visiting hours before or after these hours will be accommodated with prior arrangements being made with the office.”

R1’s Death Report was submitted to the Department on 08/16/2023 and states R1’s date and time of death as 08/14/2023 at 9:30 PM.

The facility visitation log states that R1’s Family Members, F1 and F2, visited the facility on 08/14/2023 at 9:35 AM and at 3:30 PM.

During interview, Reporting Party stated Administrator verbally agreed to allowing Resident’s family to visit from 5PM-7PM each day.

During interview, Administrator stated to have communicated with Resident’s Responsible Person that facility visitation hours are from 10AM-4PM and family usually visits for 1-2 hours. Administrator stated Resident R1's family members would stay from 10 AM, then lunch, and come back from 1 PM to 6 PM. Administrator stated the family visits outside of normal visiting hours were interfering with the care of the resident. Administrator stated to have discussed the visiting hour policy with R1’s family members multiple times.

Administrator stated during interview that on the day Resident passed on 08/14 at 9:30 PM, Administrator noticed at 6PM that Resident was visibly taking shorter breaths and notified Resident R1's family and hospice. Administrator stated to recall that F1 and F2 arrived at the facility after Administrator called F1 to notify F1 that R1 was near death. Administrator stated F1 and F2 arrived at the facility, but does not recall at what time exactly they arrived. Administrator states F1 and F2 both visited R1, but does not recall the duration that they visited R1. Administrator stated F1 and F2 told Administrator that they would be leaving to go to dinner, and F1 and F2 never returned that night. Administrator stated R1 passed away at 9:30 PM and hospice didn’t arrive and pronounce R1 deceased until 11:30 PM. Administrator stated F1 arrived at the facility sometime in the afternoon on 08/15/2023 to pick up R1’s belongings.

Page 2 of 2.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20230926140323
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: WESLEY HOUSE III
FACILITY NUMBER: 440708909
VISIT DATE: 02/27/2024
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
During interview, R1’s Family Member, F1, stated to have not been notified of R1’s passing until 11 PM on the night of R1’s passing. F1 stated that the hospice nurse notified F1 of R1’s passing. F1 stated to have not been present with R1 at the facility while R1 was passing.

R1’s Family Member F2 stated to have not been notified prior to R1’s passing that R1 was near becoming deceased. F2 stated to believe to have visited R1 the day R1 deceased, and staff told F2 that F2 could not visit past 6 PM. F2 stated to have stopped visiting R1 at 6 PM the night of R1’s passing and R1 passed away later that night.

During interview, Hospice Nurse N1 stated R1 moved into the facility on 08/09/2023 and was noted to be declining and transitioning to death on 08/10/2023. Hospice Nurse N1 stated to have arrived at the facility on 08/14/2023 at 11:15 PM and confirmed R1 was deceased. N1 stated to have then notified F1 that R1 had deceased.

During interview, staff S1 stated to have worked the night shift on the night of R1’s passing and started working that night at 6 PM. S1 stated to not recall any of R1’s family members at the facility during the time of R1’s passing.

Based on information from interviews conducted with staff, family members, and witnesses, and records reviewed, although the allegation listed above may have happened or are 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 Administrator Janet Leon and a copy of this report was provided.

Page 3 of 3.


END REPORT
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
09/26/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230926140323

FACILITY NAME:WESLEY HOUSE IIIFACILITY NUMBER:
440708909
ADMINISTRATOR:LEON, JANETFACILITY TYPE:
740
ADDRESS:123 LA SELVA DRIVETELEPHONE:
(831) 685-0646
CITY:LA SELVA BEACHSTATE: CAZIP CODE:
95076
CAPACITY:6CENSUS: 4DATE:
02/27/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Janet LeonTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not meet resident's needs
Staff did not issue a full refund
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
R1’s Family Member F1 stated that prior to R1’s admission to the facility, Administrator agreed to have staff take R1 to the outside garden area of the facility.

R1’s Hospice Evaluation Notes from 08/08/2023 say hospice provided a Hoyer lift but the “intro did not go well, and it was returned,” and the family purchased a lift that the hospice nurse had not seen before, but the patient must be sitting to use it. The Hospice Evaluation Notes say Resident cannot sit unsupported and needs two people to connect R1 to the hoyer lift. The Hospice Evaluation Notes say R1's family member was sewing a new sling for the lift that would allow R1 to be more comfortable in the sling. The Hospice Evaluation Notes state that R1 was a risk for falls, unable to bear weight, had a left rotator cuff that was bone on bone, an arthritic neck, and had lower back pain.

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

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
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 6
Control Number 26-AS-20230926140323
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: WESLEY HOUSE III
FACILITY NUMBER: 440708909
VISIT DATE: 02/27/2024
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
During interview, Administrator stated the staff turned the R1 and tried to keep R1 comfortable as much as possible. Administrator stated the hospice nurse verified with Administrator and staff that Resident was too brittle to sit on a commode or to be moved from the hoyer lift to the commode. Administrator stated the hoyer lift was never used.

During interview, Hospice Nurse N1 stated R1 moved into the facility on 08/09/2023 and was noted to be declining and transitioning to death on 08/10/2023. N1 stated It is generally not recommended to take someone out of bed when they are in their stage of actively declining towards death for reasons of safety and comfort.

R1’s Admission Agreement was signed on 08/08/2023 and R1 moved in to the facility on 08/09/2023. R1 passed away on 08/14/2023. During interview, R1’s Family Member F1 stated to have moved R1’s belongings out of the facility shortly after 12:00 AM on 08/15/2023.

LPA Marrufo obtained a copy of R1’s Processing Fee Agreement, which was signed and dated on 08/08/2023 by R1, R1’s responsible party, and Administrator. The document states that the facility processing fee for R1 of $9,500 covers the administrative costs of admitting the resident into the facility and is non-refundable.

LPA Marrufo obtained a copy of R1’s Cost of Care document, which states R1’s cost of care for the first 30 days of residency at the facility was $8,000 and was fully paid. LPA Marrufo obtained a copy of the check made from the facility to R1’s Family Member F1 on 09/04/2023 for $6,133.33.

Administrator stated to have arrived at the check amount of $6133.33 by calculating the daily costs of care, which at $8,000 for 30 days comes out to $266.66 a day and counting from the initial day R1 moved into the facility, which was 08/09/2023 to the day R1’s belongings were moved out of the facility, which was 08/15/2023, which amounts to $1,866.66 and subtracted that amount from the $8,000 for 30 days of care, which amounts to $6,133.33, the amount of the check.

Page 2 of 2.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20230926140323
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: WESLEY HOUSE III
FACILITY NUMBER: 440708909
VISIT DATE: 02/27/2024
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
This agency has investigated the complaint allegations listed. Based on interviews and review of records, the Department has found that the complaint allegations are unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report was reviewed with Administrator Janet Leon and a copy of this report was provided.

Page 3 of 3.


END REPORT
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6