445202356-1-9-2025-26-AS-AMEN-DEHPK5-20250306102235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202356
Report Date: 01/09/2025
Date Signed: 01/09/2025 11:43:33 AM

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
09/06/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230906125323

FACILITY NAME:	MONTECITO MANOR		FACILITY NUMBER:	445202356
ADMINISTRATOR:	JOLENE SICLEY		FACILITY TYPE:	740
ADDRESS:	311 MONTECITO AVE.		TELEPHONE:	(831) 724-3055
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY:	85	CENSUS: 54	DATE:	01/09/2025
		UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Ivonne Sanchez		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff caused injury to a resident in care.
Staff pushed a resident in care.
Staff left residents in a soiled diaper for a long period of time.
Staff does not shower the residents.
Staff did not keep facility free of insects.
Staff did not prevent a dog from causing injury to a resident in care.
Staff is not ensuring that residents are taking prescribed medications.
Staff calls residents inappropriate names.

INVESTIGATION FINDINGS:

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On 1/9/2025, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Assistant Manager Ivonne Sanchez and LPA explained the purpose of the visit.

Regarding the allegations of staff caused injury to a resident in care and staff pushed a resident in care, reporting party (RP) reported that there is a resident (R1) that is about 300 pounds and was observed with bruises. RP reported that R1 disclosed that he/she got pinched and pushed by the staff (S4).

LPA Marrufo was able to interview RP for additional information. According to RP, when RP asked R1 why R1 has bruises on his/her arms and R1 says “S4 pushed me to the wall so I wouldn’t fall and squeezed my hand to hard.” R1 said S4 tried to hold him/her and then punched him/her. R1 says he/she is scared of S4. RP doesn’t have photos of the bruising.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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-20230906125323

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: MONTECITO MANOR	FACILITY NUMBER: 445202356
	VISIT DATE: 01/09/2025

NARRATIVE

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LPA Marrufo also interviewed R1. R1 mentioned that he/she hasn’t observed any staff pushing or pinching residents. R1 also mentioned that he/she likes S4. S4 is a very good worker here. S4 is not cruel. There were other seven interviewed. Six out of these seven residents said that they haven’t observed staff causing injury or pushed residents. One resident, R6, had memory issues and was having a hard time keeping on topic during the interview. Four out of four staff that were interviewed all answered that they have not observed any staff causing injury or bruising to residents.

For the allegations of staff left residents in a soiled diaper for a long period of time and staff does not shower the residents, RP reported that the staff member S4, does not change the residents’ diapers and leaves them in a soiled diaper for three hours. RP also reported that S4 does not shower the residents. RP reported that residents are going approximately 5 days to a week in a half without getting a shower. RP added that there is a log for showers for all the residents. R1, R2, R3, R7 & R8 are the ones Licensing should look at for not being showered. When S4 works in Memory Care, S4 hardly showers anyone.

Based on resident interviews, R1 mentioned that they have never left him/her in a diaper for a whole day. They at least change him/her before lunch. R1 also mentioned that he/she got just one shower over seven days ago. Then got one last night (at the time of the interview). R1 said he/she is supposed to be showered at least two times a week.

R1 also mentioned that S4 is the one who does his/her showering. S4 does not drop R1 in the shower. S4 is very good and R1 respects and likes S4. R2 shared that they change him/her once in the morning, before lunch and after lunch. Before dinner and after dinner they also change him/her. R2 also mentioned that he is showered several times a week. R2 asks for showers Mondays, Wednesdays, and Fridays. Other residents who were interviewed said no if they have observed other residents left in soiled diapers and. Some residents are able to take their own showers and would request some assistance from time to time.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20230906125323

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: MONTECITO MANOR	FACILITY NUMBER: 445202356
	VISIT DATE: 01/09/2025

NARRATIVE

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Based on records review, R1, R2, R3, R7 & R8 have regular showers based on the logs provided. Some are also provided by S4.

Regarding the allegation of staff did not keep facility free of insects, RP reported that there are cockroaches in the kitchen, and sometimes get into the resident’s food. Another co-complainant, RP2, shared that there are cockroaches everywhere, in the food that we serve, in the rooms.

Based on interviews, R1 mentioned that he/she observed insects in the facility. R1 shared that the drawer (in the room) behind you (interviewer), someone pulled out the drawer and a cockroach came out. One day when R1 was having breakfast or lunch, R1 took the orange juice and turned it over to capture the bug. The bug was on the table. R4 shared that yes, he/she has seen flies. R4 probably have seen cockroaches but don’t see bugs in the meals when they are eating. R5 stated that he/she has observed bugs and cockroaches. R5 saw four cockroaches in the shower and in the dining room. R5 found a bug in his/her water but never observed a cockroach in his/her plate or food. R7 mentioned that yes, they have seen a few bugs here. They are little black ones, but they don’t seem to interfere with R7. R7 has never seen cockroaches.

LPA Marrufo interviewed S5 & S6 and both mentioned that there are no bugs or cockroaches in the kitchen. However, during S7’s interview, it was mentioned that there are cockroaches. S7 said that they don't say anything because they know they will get in trouble. S7 have seen cockroaches. They are mostly in the main assisted living kitchen and the mental care kitchen. The last time S7 saw one was this morning by the stove. S7 sees them every day. There is sometimes the open trays and the cockroaches come out.

Based on records review, video and photo evidence from RP shows bugs crawling from residents rooms and insects on loaves of breads that are still packed. However, on the records provided by the facility, the pest issue has been addressed. Pest control is scheduled monthly and during the time of this complaint, they added additional visits to the facility. Treatments have been made to target pests.
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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20230906125323

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: MONTECITO MANOR	FACILITY NUMBER: 445202356
	VISIT DATE: 01/09/2025

NARRATIVE

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Regarding the allegation of staff did not prevent a dog from causing injury to a resident in care, RP reported that there was a dog at the facility that jumped on a resident (R4) and caused an injury and RP reported that the injury was located on R4s left hand.

LPA Marrufo interviewed R4 and mentioned that a dog was playing with R4. Most people like to play with the dog. R4 was not actually trying to play with the dog. The dog just came to R4. R4 doesn’t know how he/she got this injury but also shared that the dog caused the injury on R4s arm. R4 doesn’t know if the dog bit or scratched. R4 doesn’t remember. Staff came right away and put a tape on the bruise or my cut. It bled a little. They did not call the doctor. R4 doesn’t think they called his/her family. Staff checked on R4 the next day and changed my bandage.

According to S3, there haven’t been any incidents with the dog here. The residents seem to love him. S3 knows one time the dog did a little scratch on R4. It was not really much. They were sort of rough playing with the dog at the time. S3 observed it when it happened. R4 and the dog were playing together on the couch. The dog was jumping off of R4 and scratched her. It was not big or anything. It was a light scratch. There was no bleeding. The dog scratched R4 on one of his/her arms, but don’t remember which one. After, we cleaned up the scratch and wrapped it up and asked R4 if he/she was okay. They wanted to continue play with the dog but after I told them that they should wait.

For the allegation that staff is not ensuring that residents are taking prescribed medications, RP reported that there are two med techs that are not making sure that residents are taking their medications when giving medications to the residents. RP added that he/she finds medications on the floor of the resident rooms. They just drop off the medications at the residents’ table during meals and to their rooms. They just drop off the medications without making sure they have taken the medications.

According to resident interviews, five out of eight mentioned that staff help them with medication and makes sure that they take them. R3, R6 and R8 has cognitive issues, R3 said that no one gives him/her medications and takes them himself/herself. R6 is not able to stay in topic and R8 said that staff don’t give them medications.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20230906125323

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: MONTECITO MANOR	FACILITY NUMBER: 445202356
	VISIT DATE: 01/09/2025

NARRATIVE

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During staff interviews, S1 mentioned that he/she stays with the residents until they finish taking all the medications. S1 watches to make sure they are taking each pill one at a time. There are some residents who cheek their medications. S1 asks to see inside their mouths, and they check. There aren’t any pills that are left in the resident rooms that are not consumed. S2 shared that the med techs pass out the meds individually. They wait there and wait until they finish. Some of them will open their mouth or they will wait until they open. If we see pills left behind, we will let the med tech know. S2 never see pills left in the resident rooms. S3 mentioned that the med techs watch the residents and ask them to open their mouths and lift their tongues. S3 never see any unconsumed pills left in the resident room. S4 shared that the med techs stay with the resident until the resident takes it. Sometimes the resident throws it away or hides the medication in their mouth. He/she (MedTech’s) asks to see the medication in their mouth. The MedTech leaves when he/she is sure that the residents have taken it. They need to make sure.

Regarding the allegation of staff calls residents inappropriate names, RP reported that S4 calls the residents names, calls them fat, tells them they stink and needs to shower. RP added that a lot of staff have witnessed S4 call them names. The residents complain about this too.

According to resident interviews, six out of eight mentioned that they haven’t observed any staff calling residents inappropriate names. R4 shared that he/she is the one who curses back at staff. Four out of four staff mentioned that they haven’t heard or seen any staff calling residents inappropriate names.

Based on interviews, records review and observations, the department has determined that although the allegations 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 allegations are UNSUBSTANTIATED.

Report is reviewed and copy is provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC9099 (FAS) - (06/04)

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