445202401-4-15-2025-26-AS-KHOS-DG6SSR-20250428140822

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202401
Report Date: 04/15/2025
Date Signed: 04/15/2025 03:25:36 PM

Unfounded

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
04/10/2025 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20250410092026

FACILITY NAME:	VALLEY HAVEN III		FACILITY NUMBER:	445202401
ADMINISTRATOR:	JOSEPHINE ARCILLA		FACILITY TYPE:	740
ADDRESS:	2266 CHANTICLEER AVE.		TELEPHONE:	(831) 818-8372
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	48	CENSUS: 28	DATE:	04/15/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator Josephine Arcilla		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are sedating resident.
Staff do not ensure resident is being fed resulting in weight lost.
Staff are not providing resident nutritious foods.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 4/10/2025 the Department received a complaint alleging that staff are sedating resident 1 (referred to as R1).

On 4/14/2025 LPAs interviewed Witness 1 and Witness 2 (referred to as W1 and W2). W1 and W2 states R1 is being sedated because R1 attempts to get out of his/her wheelchair. Both W1 and W2 do not know what medications are used to sedate R1, and do not know what medications are prescribed to R1. W1 and W2 stated they do not know R1’s medical diagnosis.

On 4/15/2025 LPAs Marcella Tarin and Manuel Monter conducted the initial complaint investigation. LPAs interviewed 5 staff (referred to as S1-S5), and 5 residents (referred to as R1-R5) regarding the above allegation.
Page 1 of 4

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

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 4

Control Number 26-AS-20250410092026

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: VALLEY HAVEN III	FACILITY NUMBER: 445202401
	VISIT DATE: 04/15/2025

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

5 out of 5 staff state he/she has not observed R1 being sedated by staff. All staff interviewed stated R1 does attempt to stand up from his/her wheelchair. All staff interviewed stated staff will redirect R1 with other choices such as walks, snacks, using the restroom or sitting in a different chair. All staff interviewed stated if R1 continues to be restless and agitated, a PRN medication can be administered.

LPAs interviewed ADM. ADM stated the facility is not sedating R1. ADM stated R1 is given PRN medication for agitation/restlessness when needed. ADM stated facility staff will attempt to redirect R1 before a PRN medication is possibly administered.

On 4/15/2025 LPAs interviewed W3. W3 stated they have not observed facility staff intentionally sedating R1. W3 stated he/she has no issues with medications and his/her family members health and safety at the facility.

On 4/15/2025 LPAs interviewed hospice staff H1 and H2. H1 and H2 stated they have not observed facility staff intentionally sedating R1. H1 and H2 stated there has not been any discrepancies regarding R1’s medications being over-administered. H1 and H2 stated R1 does attempt to get up from his/her wheelchair but have observed staff redirect R1. H1 and H2 stated if R1 continued to be agitated, then staff would administer PRN medication.

LPAs reviewed R1’s medications. LPAs cross-referenced the Centrally Stored Medication and Destruction Record (CSMDR) with the Medication Administration Record (MAR), and the medication containers/bottles. No discrepancies were noted.

The Department has completed the investigation of the above allegation. Based on interviews conducted and records review, the department has found that the above allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or are without a reasonable basis.

Page 2 of 4

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 26-AS-20250410092026

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: VALLEY HAVEN III	FACILITY NUMBER: 445202401
	VISIT DATE: 04/15/2025

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

Staff do not ensure resident is being fed resulting in weight lost/Staff are not providing resident nutritious foods.

On 4/10/2025 the Department received a complaint alleging staff are not ensuring R1 is being fed resulting in weight loss, and staff are not providing R1 nutritious meals.

On 4/14/2025 LPAs interviewed W1 and W2. W1 and W2 state staff are not ensuring that R1 is being fed, resulting in weight loss. W1 and W2 were unable to provide additional details regarding R1s weight loss. W1 and W2 stated the staff are feeding R1 cakes, cookies and sugary drinks (lemonade). W1 and W2 stated they do not know if R1 has any dietary restrictions and do not have knowledge of R1’s medical diagnosis. W2 stated he/she is not a dietician and cannot say for sure if the meals meet R1’s needs.

On 4/15/2025 LPAs interviewed R1-R5. 4 out of 5 residents interviewed stated staff help with eating. R2 stated he/she does not need assistance with eating. All residents interviewed stated the facility provides meals that are balanced and meet their needs. R1 stated he/she does receive assistance when eating. R1 states the meals are meeting his/her needs.

LPAs interviewed 5 staff S1-S5 and ADM. All staff and ADM stated they assist residents with eating, if needed. All staff and ADM stated if a resident is sitting with a full plate of food or is struggling to eat, staff will assist resident with eating their food. All staff and ADM stated that the facility is providing well-balanced and nutritious meals to residents that include proteins, carbohydrates and fresh vegetables or salads.

LPAs interviewed W3. W3 stated he/she has no issues/concerns with R1s weight, or the food provided by the facility.

Page 3 of 4.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20250410092026

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: VALLEY HAVEN III	FACILITY NUMBER: 445202401
	VISIT DATE: 04/15/2025

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

LPAs interviewed hospice staff H1 and H2. Both H1 and H2 stated R1 has not had a significant change in weight and R1’s weight has been consistent in the past 6 months. H1 and H2 stated they have observed facility staff assisting R1 with eating. H1 and H2 stated the facility is providing meals that are meeting R1’s needs. H1 and H2 stated based on R1’s physicians report, R1 does not have any dietary restrictions.

LPAs toured facility kitchen and observed staff preparing lunch. Staff were cooking mixed vegetables, chicken with marinara sauce, scalloped potatoes and bread pudding with raisins.

LPAs observed R1 eating during lunch. LPAs observed R1 was eating his/her lunch independently at a slow pace.

LPAs reviewed R1 weight record from 11/2024 to 4/2025, R1s weight ranged between 186lbs to 192lbs.

Based on review of R1’s physicians report 07/12/2024, R1 does not have any dietary restrictions.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited during today's visit. An exit interview was conducted with Administrator Josephine Arcilla and signed copy of this report was provided.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4