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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202643
Report Date: 09/18/2024
Date Signed: 10/25/2024 04:48:59 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
03/14/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20230314081243
FACILITY NAME:AMY'S RESIDENTIAL CARE, INC.FACILITY NUMBER:
435202643
ADMINISTRATOR:SINGH, JAGTARFACILITY TYPE:
740
ADDRESS:671 N WHITE RDTELEPHONE:
(408) 898-8784
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 5DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Amarjeet MannTIME COMPLETED:
01:13 PM
ALLEGATION(S):
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Staff are not brushing residents teeth.
INVESTIGATION FINDINGS:
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On 10/25/2024, Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the amended investigation finding report initially issued on 9/18/2024. LPA met with Administrator (ADM) Amarjeet Mann. This complaint allegation is being amended after new information has been received by the Department,

On 3/14/2023, the Department received a complaint with the above allegation.

On 3/17/2023, the Department conducted an initial investigation visit. LPA interviewed 3 staff and 6 residents.

LPA requested resident Physician’s Report’s, Appraisal/Needs and Service Plan and schedule of staff.
Continue on LIC-9099-C. Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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 6
Control Number 26-AS-20230314081243
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: AMY'S RESIDENTIAL CARE, INC.
FACILITY NUMBER: 435202643
VISIT DATE: 09/18/2024
NARRATIVE
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Staff are not brushing residents teeth:

On 3/17/2023, LPA interviewed Administrator (ADM) ADM stated all the 6 residents need help to brush teeth. ADM stated the staff help residents to brush teeth twice per day. ADM stated all 6 residents cannot communicate very well.

LPA interviewed staff S1. S1 stated all 6 residents need help to brush teeth. S1 stated all 6 residents receives teeth brushing twice per day.

LPA interviewed staff S2. S2 stated all 6 residents need help to brush teeth. S2 stated 5 out 6 residents receive twice teeth brushing per day. S2 stated 1 out of 6 resident needs to take out the denture to clean.

LPA interviewed 6 residents. 3 out 6 residents were unable to answer the questions. 2 out 6 residents stated they can brush teeth by themselves. 1 out of 6 resident was unable to confirm how often he/she receives teeth brushing. LPA looked at resident R1's teeth, LPA did not see food left in the mouth or left on the teeth. LPA was unable to find out R1's teeth has oral hygiene issue.

Based on the interviews and observation, there is no evidence that the staff are not brushing residents' teeth.

The Department has investigated the above allegations. Based on the investigation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s complaint investigation visit. Exit interview was conducted with ADM. A copy of this report was provided to ADM.

Page 2 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
03/14/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20230314081243

FACILITY NAME:AMY'S RESIDENTIAL CARE, INC.FACILITY NUMBER:
435202643
ADMINISTRATOR:SINGH, JAGTARFACILITY TYPE:
740
ADDRESS:671 N WHITE RDTELEPHONE:
(408) 898-8784
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 6DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Amarjeet MannTIME COMPLETED:
01:13 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not take resident to the doctor.
INVESTIGATION FINDINGS:
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3
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5
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7
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9
10
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13
On 10/25/2024, Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the amended investigation findings initially issued on 9/18/2024. LPA met with Administrator (ADM) Amarjeet Mann. This complaint allegation is being amended after new information has been received by the Department,

On 3/14/2023, the Department received a complaint with the above allegation.

On 3/17/2023, the Department conducted an initial investigation visit. LPA interviewed 3 staff and 6 residents.

LPA requested resident Physician’s Report’s, Appraisal/Needs and Service Plan and schedule of staff.
Continue on LIC-9099-C. Page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20230314081243
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: AMY'S RESIDENTIAL CARE, INC.
FACILITY NUMBER: 435202643
VISIT DATE: 09/18/2024
NARRATIVE
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Staff did not take resident to the doctor:

The allegation is that the facility did not make a doctor appointment for resident R1after R1 obtained an eye injury in February 2023.

On 3/17/2023, LPA interviewed ADM. ADM stated the facility helps resident R1 for doctor appointment. ADM stated R1's has eye doctor appointment on 3/28/2023.

During LPA's visit, resident R1 was observed with a red eye on his/her left side. LPA interviewed R1. R1 nodded his/her head when was asked if he/she wanted to see eye doctor, but was still waiting.

On 10/17/2024, LPA interviewed House Manger (HM). HM stated R1 had eye injury on 2/14/2023 or 2/15/2023 around 7-8 PM when staff was transferred R1 from wheelchair to bed and R1 obtained accidentally injury by hitting the head of the bed.

HM stated R1 did not obtain bruise or open wound during the incident. HM stated R1's eye was not observed red for the first 3-4 days after the occurrence of the incident. HM stated the facility contacted R1's family doctor on 2/18/2023 for R1's red eye. HM stated the doctor prescribed OTC eye drop and ointment for R1 as needed. HM stated on 3/3/2023 R1's family doctor referred R1 to an eye doctor. HM stated the facility made an eye doctor appointment for R1 on 3/28/2023. R1's eye worsen after the occurrence of eye injury on 2/14/2023 or 2/15/2023.

Based on the interviews and observation, resident R1 had eye injury and red eye, the facility staff administered doctor prescribed OTC medications to R1. The facility made eye doctor appointment for R1 more than one month after the occurrence of the eye injury.


Continue on LIC9099-C. Page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20230314081243
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: AMY'S RESIDENTIAL CARE, INC.
FACILITY NUMBER: 435202643
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2024
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed ...(1) The licensee shall arrange ...for medical and dental care appropriate to the conditions and needs of residents.
This requirement was not met as evidenced by:
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Administrator stated he/she will submit plan of correction by the POC due date to ensure staff to seek for timely medication attention and arrange doctor appointment for resident.
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Based on interview and record reviewed, R1 sustained an eye injury on 2/14/2023 or 2/15/2023, R1's eye worsen before the scheduled eye doctor appointment. The facility did not seek for timely medical attention for resident R1 which poses an immediate health, and safety risk to persons in care.
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CCR
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20230314081243
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: AMY'S RESIDENTIAL CARE, INC.
FACILITY NUMBER: 435202643
VISIT DATE: 09/18/2024
NARRATIVE
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Based on the interviews and observation, the facility did not seek timely medical attention for R1's eye injury and took more than one month to make doctor appointment.

The Department has investigated the above allegations and the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies were cited per California Code of Regulations, Title 22. See LIC9099-D.

Exit interview was conducted with ADM. This report was provide to ADM for signature. A copy of the report was provided to ADM.

Page 3 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6