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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202403
Report Date: 08/28/2024
Date Signed: 08/28/2024 02:39:36 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
04/04/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220404134358
FACILITY NAME:EBADAT RESIDENTIAL CARE HOME #4FACILITY NUMBER:
435202403
ADMINISTRATOR:DIOSDADO S. ARINESFACILITY TYPE:
740
ADDRESS:243 MARTINVALE LN.TELEPHONE:
(408) 622-6293
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY:6CENSUS: 4DATE:
08/28/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Rad MurilloTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident developed dehydration while in care.
Resident developed pressure injuries while in care.
INVESTIGATION FINDINGS:
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On 8/28/24, LPA Grace Donato conducted an unannounced a complaint investigation visit and met with Care Staff Rad Murillo. LPA explained the purpose of the visit.

Regarding the allegation of resident (R1) developed dehydration while in care & developed pressure injuries while in care. Reporting party states that Client was dehydrated and had pressure wounds on the elbows, heels, and coccyx. RP did not know the stage level of the wounds and it was not indicated in the client's medical chart.

LPA was able to interview two staff members. S1 mentioned that R1 is with the facility for 21 years and can take a few steps from living room to dining room. Staff observed R1s right leg swollen and there was no fall or bruise so S1 instructed staff to elevate the leg and do ROM (Range of Motion) on arm.

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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
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-20220404134358
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: EBADAT RESIDENTIAL CARE HOME #4
FACILITY NUMBER: 435202403
VISIT DATE: 08/28/2024
NARRATIVE
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S1 said they wanted to wait and see if the swelling will go down before sending to the hospital since vital signs were good. However, the following day, staff found R1 not as responsive when staff asked R1 for breakfast. S1 asked staff to check on vital signs and they were good but looked pale and weak so S1 instructed staff to call 911. Another staff member, S2 also mentioned that they have tried and elevated R1s leg but the following day R1 did have a change in condition as R1 looked pale and weak. S2 also shared that residents in the facility are always provided hydration every hour, even before going to bed. LPA tried to get in touch with RP but there was no response.

Based on records review, facility sent an incident report indicating that they had called 911 for further checkup due to their observations of R1 being weak while being assisted getting up from bed, a swelling of left arm and an open wound on left elbow measuring about 3cm, swollen right leg and redness on buttocks and swollen ankle.

Based on interviews & records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.



Report is reviewed and copy is provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
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