430702959-11-30-2023-26-AS-JJIN-D7FU3G-20240723151328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430702959
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:48:46 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
03/15/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230315144631

FACILITY NAME:	JULIET STEPHEN REST HOME		FACILITY NUMBER:	430702959
ADMINISTRATOR:	OLIVA, DOMINICA		FACILITY TYPE:	740
ADDRESS:	909 COLLEGE DRIVE		TELEPHONE:	(408) 298-9502
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	6	CENSUS: 6	DATE:	11/30/2023
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Dominica Oliva		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Resident sustained a pressure injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. LPA met with Administrator, Dominica Oliva.

On 03/15/2023, the Department received the complaint alleging resident (R1) sustained a pressure injury while in care of the facility. On 03/16/2023, the initial complaint investigation was conducted.

During the investigation, it was found prior to admission R1 already had sustained a pressure injury on the right heel and buttox that was not honestly disclosed and observed during the admission process. After observing the pressure injury, the facility’s Licensee requested home health service for R1 to receive wound care. After months of the pressure ulcer teetering between improving and getting worse again from receiving wound treatment, the Licensee requested a referral to a wound care clinic at a hospital. SEE LIC9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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-20230315144631

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: JULIET STEPHEN REST HOME	FACILITY NUMBER: 430702959
	VISIT DATE: 11/30/2023

NARRATIVE

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While receiving wound care treatment, it was discovered that R1’s pressure ulcer would likely not heal without vascular intervention, however, R1 was too weak to undergo any vascular intervention. The clinic decided to treat the wound conservatively instead. Staff followed instructions from the wound care doctor and demonstrated their understanding to the home health nurses.

Staff reported and documented that R1 had frequent visitors that removed R1’s wound dressings and the boots R1 was to continuously wear to off-load the wound. Despite staff telling R1’s visitors to not remove it, R1’s visitors did not listen. R1’s responsible party and home health nurses were aware of the situation with R1’s visitors. Facility staff were instructed to be firm with the visitors to not interfere with R1’s care.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is UNFOUNDED meaning the allegation is false, could not have happened, and/or is without a reasonable basis.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Dominica Oliva and a copy of the report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

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