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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430708736
Report Date: 09/28/2024
Date Signed: 09/28/2024 02:54:12 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
06/23/2023 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20230623154414
FACILITY NAME:VILLA VERDEFACILITY NUMBER:
430708736
ADMINISTRATOR:JULIETA EXTRAFACILITY TYPE:
740
ADDRESS:4751 CALLE DE TOSCATELEPHONE:
(408) 978-7937
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 4DATE:
09/28/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Licensee, Dominica OliviaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not provide adequate care for resident’s wound.
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 today’s visit.

On 6/23/2023, the Department received a complaint with the above allegations. On 6/28/2023, the Department conducted an initial investigation at the facility.


Continuation on LIC 9099-C, Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024
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 2
Control Number 26-AS-20230623154414
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: 09/28/2024
NARRATIVE
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Page 2 of 2.

It was alleged that the facility did not provide adequate care for the resident R1’s wound on right foot which resulted wound being infected by maggots.

On 10/28/2022. The Department received Incident Report for R1 wherein R1 was sent to the hospital due to ADM noticed an unusual smell and observed wound on right foot.

Based on review of R1’s Appraisal/Needs and Services Plan dated 7/3/2021, R1 takes walks regularly and R1 is able to do functions of daily living. R1 needs assistance in housekeeping and medication. Based review of R1’s Physician’s Report dated 6/23/2021, R1 is has a mental health diagnosis and R1 able to leave the facility unassisted. R1 is not able to administer own prescription medications and not able to store own medication.

On 9/28/2024, LPA Rai interviewed 1 staff (S1) who is aware of incident regarding R1. S1 stated the facility staff only assisted R1 with medication and housekeeping as R1 was independent with all other Activities of Daily Living (ADLs). R1 was able to grooming, bath/shower and dress himself/herself. S1 stated the staff did not observe R1 had wounds before this incident and R1 did not have any home health services for wound care.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, 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 from California Code of Regulations, Title 22. Exit interview conducted with Licensee, Dominica Olivia and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2