445202356-8-10-2023-26-AS-KHOS-CYENU7-20231211094553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202356
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:00:51 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
01/23/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20230123135459

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: 49	DATE:	08/10/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Ivonne Sanchez		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained fractures while in care

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 Ivonne Sanchez, Facility Manager.

On 01/23/2023, the Department received a complaint with the above allegation. On 01/24/2023, the Department conducted an initial complaint investigation visit.

Medical records revealed that resident R1 was admitted to the hospital on 01/16/2023 and diagnosed with an intertrochanteric fracture of R1’s femur and a fracture of the upper end of R1’s humerus. On 01/16/2023, R1 was transported to the hospital. R1’s hospital medical records revealed R1 had surgery on 01/17/2023 for R1’s intertrochanteric fractured femur.

See LIC9099-C for more information. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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-20230123135459

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: 08/10/2023

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

On 01/16/2023, facility staff S1 and S2 were working and overheard R1 yelling for help. S1 and S2 found R1 on the floor of the Memory Care unit of the facility. S1 and S2 did not know how R1 fell. R1 told S2 that R1 lost R1’s balance and fell. S2 called 911 for R1 to be taken to the hospital. S1 and S2 were aware that R1 had an unwitnessed fall and injured R1’s left shoulder and left hip.

After several staff interviewed and review of R1’s resident records, R1 was found to not be a fall risk and to not have a fall history. R1 was admitted to the facility without a walker.

Based on information from interviews conducted with staff and records reviewed, although the allegations listed above may have happened or are 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

This report was reviewed with Ivonne Sanchez, Facility Manager, and a copy of this report was provided.

Page 2 of 2.

END REPORT

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2