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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202876
Report Date: 12/21/2024
Date Signed: 12/21/2024 05:14:48 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
05/17/2024 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20240517154107
FACILITY NAME:FAMILY SENIOR CARE HOME IFACILITY NUMBER:
435202876
ADMINISTRATOR:BAUTISTA, ELIZABETHFACILITY TYPE:
740
ADDRESS:2898 GLEN FROST COURTTELEPHONE:
(408) 802-7727
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 4DATE:
12/21/2024
UNANNOUNCEDTIME BEGAN:
04:35 PM
MET WITH:Lead Staff, Jose CruzTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility food does not meet the recommended dietary allowance.
Facility staff restricting resident from voicing concern.
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 the Lead Staff, Jose Cruz and stated the purpose of today’s visit. Administrator Elizabeth Bautisita was not able to be present during visit, so LPA Rai spoke with Administrator over the phone and stated the purpose of today's visit

On 5/17/2024, the Department received a complaint with the above allegations. On 5/24/2024, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 3.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
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 3
Control Number 26-AS-20240517154107
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: FAMILY SENIOR CARE HOME I
FACILITY NUMBER: 435202876
VISIT DATE: 12/21/2024
NARRATIVE
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Page 2 of 3.
Facility food does not meet the recommended dietary allowance.
On 5/24/2024, the Department interviewed 3 staff (S1-S3). Three out of three staff prepare the meals and snacks to the residents. All three staff stated the meals and snacks provided are nutritious and cooked fresh before served. S3 stated R1 is provided protein shakes, requested fruits and consumes all meals served to R1 since R1 has a good appetite. S3 stated R1’s family will provide snacks such as dried fruits and snacks and they are always available for R1 in the resident’s room.

On 5/24/2024, the Department interviewed 4 residents (R1-R4). Four out of four residents refused to answer LPA Rai’s questions and refused to be interviewed.

During 5/24/2024 visit, LPA Rai observed 2 days of perishable foods and 7 days of non-perishable foods in the kitchen, pantry, and garage. The foods observed was a variety of frozen and cooked protein, vegetables, carbs, and canned foods. LPA Rai observed snacks in R1’s room which included dried fruit, nuts, and packaged items.

Based on review of R1’s Admission Agreement dated 5/6/2024, the facility staff is to provide basic services which include food services to include 3 nutritious meals daily and snacks and special diets if prescribed by a doctor. Based on facility house rules, all residents received 3 meals a day in the dining room and Snacks are available at all times. Based on review of R1’s Physician’s Report dated 6/1/2023, R1 has a special diet due to resident has a diagnosis of End-Stage Renal Disease (ESRD) and R1 is not able to feed self. Based on review of R1’s Appraisal/Needs and Services Plan dated 12/30/2023, R1 goes to dialysis 3 times a week and R1 needs assistance with feeding and requires a regular diet with low sugar.

Based on review of text messages between Administrator and facility staff, facility staff were aware of R1 needed more protein in diet and more food intake due to R1 losing weight. ADM instructed facility staff to ask R1’s preference and to include it with grocery shopping.

Based on review of R1’s Progress notes from 2/26/2024 to 5/6/2024, facility staff documented the resident would come back from dialysis hungry and thirsty and some meals were provided to the resident were documented. Based on review of staff training from January 2024 to June 2024, staff have completed training in the following topics which include Dehydration and Proper Nutrition and Activities of Daily Living.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20240517154107
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: FAMILY SENIOR CARE HOME I
FACILITY NUMBER: 435202876
VISIT DATE: 12/21/2024
NARRATIVE
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Page 3 of 3.
Facility staff restricting resident from voicing concern.
On 5/24/2024, the Department interviewed 3 staff (S1-S3). Three out of three staff they have not seen or heard staff restricted resident R1 from talking or communicating R1’s needs. All three staff have provided direct care to resident R1. Three out of three staff stated R1 is able to communicate to staff for assistance and express concerns directly to the Administrator. S3 stated R1 will yell of the tv in the next room is loud and staff have told R1 to “quiet down" after the issue has been resolved but they do not tell R1 to not restrict R1 from voicing any concerns about R1's care or about the facility.

On 5/24/2024, the Department interviewed 4 residents (R1-R4). Four out of four residents refused to answer LPA Rai’s questions and refused to be interviewed.

Based on review of staff training from January 2024 to June 2024, staff have completed training in the following topics which include Discrimination and Harassment and Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders.

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 Lead Staff Jose Cruz and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3