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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202876
Report Date: 07/11/2025
Date Signed: 07/11/2025 11:19:49 AM

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
04/11/2025 and conducted by Evaluator Marcela Yanez
COMPLAINT CONTROL NUMBER: 26-AS-20250411172923
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: 1DATE:
07/11/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Elizabeth BautistaTIME COMPLETED:
11:29 AM
ALLEGATION(S):
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Staff are not administering medication based on physician's orders
Staff are falsifying resident's medication records
Staff are not following infection control protocol by using one pair of gloves on mutiple residents, causing a resident to have an e.coli infection
Staff did not ensure resident's medications are locked and inaccessible to residents in care
INVESTIGATION FINDINGS:
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On 07/11/25 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint inspection visit to deliver the findings on the above allegations. LPA met with Administrator Elizabeth Bautista and stated the purpose of the visit.

On 04/11/2025 the Department received the complaint and on 04/21/2025 LPA conducted an initial complaint investigation visit. LPA attempted to interview 2 residents (R1 and R2). LPA interviewed the administrator (ADM), 1staff (S1), reporting party (RP) and 2 witnesses (W1 and W2).

On 5/23/2025, LPA conducted a continuation of the complaint investigation and re-interviewed the administrator and requested for copies of 3 resident records such as but not limited to physician’s report, vital /blood pressure (BP) logs, after visit summary log, centrally stored medication record (CSMDR) appraisal needs and services plan.
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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
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-20250411172923
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: 07/11/2025
NARRATIVE
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Staff are not administering medication based on physician’s order.

On 4/21/2025 LPA interviewed Staff 1 (S1), Administrator (ADM), witness 2 (W2) and attempted to interview 2 residents (R1, R2) and attempted to interview S2. Based on interview, S1 stated, staff administer medication based on doctor’s orders. ADM stated that the staff logs the vital readings via text message for 3 residents and provided copies and screenshots of vital record logs to LPA. ADM stated that the facility administers medication according to doctors’ order. ADM stated that R3s medication was changing frequently. W2 stated, he/she is not familiar with R2s care because he/she is out of town and have hired Senior Generation Advocate Services to assist and oversee R2s care.
Based on document review of the physician’s order, medication will be administered or given when R3’s blood pressure (BP) is too high and no medication for BP given when BP is too low.

Staff are falsifying resident's medication records.

Based on record review of the facility’s Centrally Stored Medication and Destruction Record (CSMDR), LPA observed that the prescription medication is given per physician’s order and recorded based on the doctor’s instruction. ADM stated the vital record log is used to log the BP medication for R3 and reported to R3s PCP as instructed by the PCP.
On 05/29/2025, LPA interviewed W1, who stated that he/she is the one who “noticed that the vital or blood pressure (BP) log looked suspiciously perfect and looked like it’s falsified.” LPA observed that vital / BP record presented by W1, and RP does not have R3s name or another resident’s name on BP log. LPA reviewed 2 out 2 residents’ (R1 and R2) vital / BP record and did not find the “suspiciously perfect and looked like it’s falsified” document. W1 stated, he/she found the vital / BP log on a clip board and took a photo the log was not in R3s file record. The log did not have any name on it and it is unknown who it belonged to.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20250411172923
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: 07/11/2025
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Staff are not following infection control protocol by using one pair of gloves on multiple residents, causing a resident to have an E. coli infection.

Based on review of the facility record and observation during the complaint investigation visit, the facility has infection control plan and is adhering to California Code of Regulation (CCR) Title 22 87470 Infection Control Plan Requirement. ADM stated the facility follows infection control procedures when providing care to residents. Staff always wears gloves and layers the gloves each time they attend to the resident and discarded in between completing an interaction with one resident and prior to interaction with another resident. LPA observed hand sanitizers, alcohol, and disinfecting wipes to mitigate any possible contamination between individuals.

Staff did not ensure resident's medications are locked and inaccessible to residents in care.

During visit LPA observed the medication storage closet was locked and not accessible to residents in care. ADM stated the only time medication door is unlocked is when the staff are preparing and administering the medication.

Based on information from interviews conducted and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No citations noted at today’s compliant investigation visit. Exit interview conducted with Administrator. This report was provided to review and for signature. A copy of this report was provided to Elizabeth Bautista, Administrator.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
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