430708589-6-14-2021-26-AS-RMAO-C4NPQK-20210706113117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708589
Report Date: 06/14/2021
Date Signed: 06/14/2021 03:17:50 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/29/2021 and conducted by Evaluator Joanne Roadilla

COMPLAINT CONTROL NUMBER: 26-AS-20210129142748

FACILITY NAME:	BONHOMIE IV - WILLOWMONT		FACILITY NUMBER:	430708589
ADMINISTRATOR:	PIA BELTRAN		FACILITY TYPE:	740
ADDRESS:	1583 WILLOWMONT AVENUE		TELEPHONE:	(408) 978-5211
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	6	CENSUS: 3	DATE:	06/14/2021
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Gladys Smart		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Neglect/lack of care and supervision which resulted in resident sustaining multiple pressure injuries while in care.
Staff did not ensure a resident was properly fed while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Joanne Roadilla and Ryker Heberle conducted an unannounced complaint visit to deliver the investigation findings on the above allegations. LPA spoke to Administrator (ADM) Gladys Smart and discussed the purpose of the visit.

On 01/29/2021, the Department received a complaint with the above allegations and conducted an initial unannounced 10-day tele-visit on the same day. The Department obtained resident and staff facility records.

Between 02/02/21 and 03/17/21, the department conducted interviews of facility administrator (ADM), staff and witnesses. The department also obtained resident’s (R1) medical records. Continued on 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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-20210129142748

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BONHOMIE IV - WILLOWMONT	FACILITY NUMBER: 430708589
	VISIT DATE: 06/14/2021

NARRATIVE

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From interviews and records review, the department learned that R1 was admitted at the facility on 12/26/20 after being discharged from the hospital. On 12/30/20, home health staged R1’s pressure injuries as being stage 2. Medical records indicated that R1 had multiple stage 2 pressure injuries when R1 was discharged from the hospital prior to R1 being admitted to the facility. Review of R1’s facility records showed the pressure injuries were documented upon admission and home health was being provided to R1 for the wound care from 12/26/20 to 01/27/21.

During interview of facility staff, 4 out of 4 staff stated that R1 is being provided with 3 full meals (breakfast, lunch and dinner) as well as snacks between meals. Staff stated that R1 is not on a special diet and is served meals at the same time as the other residents. The facility serves R1 meals like eggs, bacon, oatmeal, sandwiches, soup, stew, meat and vegetables. Staff also stated that R1 is provided with fruits with every meal because it’s R1’s favorite. If R1 refuses to eat, staff stated that they would encourage or even help R1 eat. Staff would sometimes ask if R1 prefers specific food which they would prepare. Staff stated that R1 had a good appetite most of the time, R1 does not finish 100% of the food prepared but would always finish all the fruits so staff would always make sure R1 has fruits available in the room to eat.

The Department has completed the investigation of the above allegations. Based on staff interviews 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. Report was discussed with and a copy provided to Gladys Smart.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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