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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430708150
Report Date: 06/21/2023
Date Signed: 06/21/2023 03:24:54 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
02/19/2020 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20200219095259
FACILITY NAME:COLLEGE MANORFACILITY NUMBER:
430708150
ADMINISTRATOR:CORA REYESFACILITY TYPE:
740
ADDRESS:760 LEIGH AVENUETELEPHONE:
(408) 293-3745
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:6CENSUS: 6DATE:
06/21/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Dominica OlivaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained pressure sore while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced complaint visit to deliver the investigation finding for the above allegation. LPA met with Licensee, Dominica Oliva.

On 02/19/2020, the Department received a complaint regarding the above allegation. On 02/21/2020, Licensing Program Analyst (LPA) Karen Taku conducted an initial 10-day compliant visit and met with Administrator Cora Reyes. LPA Taku obtained copies of resident records including, but not limited to, admission agreement, emergency contact information, physician’s report, assessments, appraisal needs and services plan, and outside health agency reports. SEE LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
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-20200219095259
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: COLLEGE MANOR
FACILITY NUMBER: 430708150
VISIT DATE: 06/21/2023
NARRATIVE
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Due to the COVID-19 pandemic, on-site facility visits were suspended to prevent the spread of the virus.

On 5/05/2020, LPA Taku interviewed facility staff (S1-S3) via tele-visit. 3 out of 3 staff stated R1 was treated for a pressure injury while in care by a home health agency. S1 – S3 states R1 was bed-bound and required staff assistance with activities of daily living (ADLs). S1 – S2 states it would take about 2-3 caregivers to transport R1 to and from the wheelchair, assist with bathing, changing, and feeding. S2 stated R1’s routine which included getting R1 out of bed daily for meals and per R1’s request.

On 06/06/2023, LPA Dolores interviewed a former staff (W1). W1 states R1 was being repositioned every 2 hours, and most especially when assisted with incontinence.

Based on record review, R1 was admitted to the facility on 05/01/2019. R1’s Functional Capability Assessment dated 05/01/2019, indicates that R1 uses a wheelchair, is able to reposition from side to side, but needs help with bathing/showering, dressing, toileting, and personal hygiene. A Home Health note dated 01/07/2020, showed that R1 was evaluated and assessed by a Home Health medical professional for R1’s pressure ulcer. The review of records states the wound was healed on 02/04/2020.

The Department has investigated the above allegation. Based on interview, record review, and observation the Department has investigated the above allegation is unsubstantiated. An unsubstantiated finding means although the allegations may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee, Dominica Oliva and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC9099 (FAS) - (06/04)
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