430708736-2-13-2024-26-AS-RMAO-D79QM4-20240717121653

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708736
Report Date: 02/13/2024
Date Signed: 02/13/2024 05:46:07 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
08/15/2023 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230815094915

FACILITY NAME:	VILLA VERDE		FACILITY NUMBER:	430708736
ADMINISTRATOR:	JULIETA EXTRA		FACILITY TYPE:	740
ADDRESS:	4751 CALLE DE TOSCA		TELEPHONE:	(408) 978-7937
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	6	CENSUS: 6	DATE:	02/13/2024
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Licensee, Dominica Olivia		TIME COMPLETED:	05:55 PM

ALLEGATION(S):

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Staff did not reposition resident every two hours causing resident's pressure injury to worsen

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Licensee, Dominica Olivia and stated the purpose of the visit.

On 8/15/23, the Department received an allegation of neglect and lack of supervision that staff did not reposition a resident every two hours causing a resident’s pressure injury to worsen.

Based on interviews with staff, R1 developed stage 2 pressure injury on his/her buttocks on 5/18/23. Staff (S1 and S2) discovered a bloody scratched blister on R1’s tailbone. On the same day, S1 called R1’s responsible party requesting home health nurse to look at the wound. At 1315 hours, R1 was seen by a home health nurse who instructed staff to use Thera Honey and covered it with a bandage. Staff were taught how to clean the wound as well and to check the wound daily.

Continuation LIC 9009-C, Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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-20230815094915

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: VILLA VERDE	FACILITY NUMBER: 430708736
	VISIT DATE: 02/13/2024

NARRATIVE

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Furthermore, staff also stated that staff followed nurse’s instruction including repositioning, put a pad below R1 and turned him/her to either side and also put pillow behind her/him because R1 could not turn on his/her own and needed staff to turn him/her. R1’s undergarment were frequently changed every 30 minutes and checked every two hours to ensure R1’s wound did not worsen.

R1’s responsible parties were provided assurance by the home Health nurse that a medical doctor was not be needed at the time. Furthermore, between 05/20/23 until R1’s hospitalization on 05/26/23, the facility staff and ADM appraise R1’s responsible parties on R1’s condition.

Interviews with staff and ADM, they were instructed by a Home Health Nurse to clean wound, change the dressing [when nurse is not available] and reposition R1 every two hours. Based on the facility record review, staff documented they turned R1 every two hours as instructed, in addition to, cleaning and changing his/her dressing and request for additional supplies from home health but never received any per ADM. ADM purchased supplies instead but R1’s pressure injury continued to worsen.

The facility Administrator (ADM) stated that he/she reached out to R1’s responsible party numerous times to request additional home health visits, wound care supplies, as well as a referral to be seen at a wound care clinic.

Staff contacted reporting party on 05/20, 05/21, 05/22 about R1’s medical heath condition. R1 was seen by reporting party and a home health nurse between 05/18 to 05/24/23.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20230815094915

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: VILLA VERDE	FACILITY NUMBER: 430708736
	VISIT DATE: 02/13/2024

NARRATIVE

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ADM also stated he/she demanded a home health visit to R1’s responsible party as well as MD consult on what to do. ADM stated he/she asked R1s responsible party why there was a delay from the MD to refer R1 to wound clinic, and even offered to speak with the MD herself/himself. ADM contacted R1’s responsible party couple of times to follow up on the referral but no available schedule appointment at the wound clinic instead R1 was seen by his/her PCP on 5/26/23. ADM stated he/she found out later that there was some confusion on the order to the wound clinic and was told it would take 6 weeks for everything to be sorted and an appointment made wherein ADM informed responsible party that R1 really needed to be seen by MD, and finally, R1 was seen by MD.

ADM stated that R1’s responsible party brought R1’s a doughnut pillow to sit on because the pain only occurred when R1 sat down but never complained of pain during his/her showers, nor R1 never told staff that he/she was in pain. ADM also added that R1 did not want staff touching him/her or clearing his/her private areas, and staff were instructed to respect R1’s personal rights.

On 05/27/23, R1 was sent to the hospital after PCP’s assessment of R1’s wound during his/her appointment. While at hospital, R1’s wound was at Stage 4 and he/she required immediate debridement surgery and further treatment was provided.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee (LIC) Dominica Olivia. A copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC9099 (FAS) - (06/04)

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