435201557-9-13-2021-26-AS-RMAO-C75K2C-20210923073053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201557
Report Date: 09/13/2021
Date Signed: 09/13/2021 02:35:23 PM

Unsubstantiated

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
02/19/2021 and conducted by Evaluator Joanne Roadilla

COMPLAINT CONTROL NUMBER: 26-AS-20210219100622

FACILITY NAME:	PRUNERIDGE RESIDENTIAL CARE HOME		FACILITY NUMBER:	435201557
ADMINISTRATOR:	CORTES, LEILANI		FACILITY TYPE:	740
ADDRESS:	3030 PRUNERIDGE AVENUE		TELEPHONE:	(408) 247-2771
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	6	CENSUS: 5	DATE:	09/13/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Rosalia Calungcagin		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not follow hospice care plan resulting in resident's fall.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Complaint Investigation to deliver the investigation findings on the above allegations. LPA spoke to Licensee/Administrator Leilani Cortes to discuss the purpose of the visit.

On 02/19/21, the department received a complaint with the above allegations. On 02/26/21, LPA conducted an initial 10-day investigation tele-visit. LPA interviewed licensee, two regular staff (S1-S2) and two temporary staff (S3-S4) at the facility. LPA also requested for residents’ records.

Continued on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

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-20210219100622

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: PRUNERIDGE RESIDENTIAL CARE HOME	FACILITY NUMBER: 435201557
	VISIT DATE: 09/13/2021

NARRATIVE

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During licensee’s interview, licensee stated that she was notified of the incident around 8am that day. Licensee then notified the hospice nurse (RN) of the incident so they can check R1’s condition.

On 05/17/21, LPA interviewed RN. During the interview, hospice RN stated that RN visits R1 once a week and as needed. RN checks on R1’s as needed care management, and if there is any concern, licensee calls RN and RN would go and visit to check on R1. LPA interviewed RN. During the interview, RN verified a call from the licensee was recorded on 02/19/21 at 8:49am to notify RN about the incident with R1. RN stated R1 was visited and checked the day of the report.

Per staff (S2) interview, R1 is not a fall risk.

Based on records review, R1 is not a fall risk. Hospice care plan dated 10/01/20 stated per staff, no fall for the past 2 months and fall precautions reviewed/implemented with staff. There is no record of any incident of fall since R1 was admitted on 05/14/20.

The department has completed the investigation of the above allegations. Based on interviews and records review, there is no preponderance of evidence to prove the allegations did or did not occur. Therefore, the Department found the above allegations to be UNSUBSTANTIATED.

No citations were issued per the California Code of Regulations, Title 22. Report was reviewed and a copy provided to Rosalia Calungcagin.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC9099 (FAS) - (06/04)

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