435294024-7-2-2021-26-AS-RMAO-C5C3FT-20210727181316

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294024
Report Date: 07/02/2021
Date Signed: 07/02/2021 06:53:20 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
08/21/2019 and conducted by Evaluator Joanne Roadilla

COMPLAINT CONTROL NUMBER: 26-AS-20190821115337

FACILITY NAME:	PACIFIC GARDENS		FACILITY NUMBER:	435294024
ADMINISTRATOR:	ZAHODNE, MATTHEW		FACILITY TYPE:	740
ADDRESS:	2384 PACIFIC DR		TELEPHONE:	(408) 985-5252
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	104	CENSUS: 50	DATE:	07/02/2021
		UNANNOUNCED	TIME BEGAN:	05:43 PM
MET WITH:	Matt Zahodne		TIME COMPLETED:	06:20 PM

ALLEGATION(S):

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Eviction notice issued to resident does not meet SB781- Eviction Procedure.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Complaint visit today to deliver the investigation finding on the above allegation. LPA met with Executive Director (ED) Matt Zahodne and explained the purpose of the visit.

On 08/21/19, the department received a complaint with the allegation that the eviction notice issued to resident (R1) does not meet SB781 – Eviction Procedure. On 09/03/19, LPA Santos conducted an initial 10-day investigation. LPA interviewed ED regarding the eviction notice served to R1’s responsible party (RP). The department was provided with a copy of the eviction letter and documents that were received by RP from ED.

Continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

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-20190821115337

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: PACIFIC GARDENS	FACILITY NUMBER: 435294024
	VISIT DATE: 07/02/2021

NARRATIVE

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Based on the review of the eviction notice issued to R1’s RP on July 30, 2019, the letter noted that through a previous meeting with RP, ED had reported that R1 has been physically and verbally aggressive towards the staff at the facility. The letter stated an incident on June 11th wherein R1 caused physical injury to one of the staff. The letter also included a statement that ED has started receiving daily reports of similar behaviors of verbal aggression and almost daily reports of physical aggression by R1 that were witnessed by several staff members. The eviction notice also provided RP with a list of Senior Housing Information and Referral from Santa Clara County Network of Care as well as contact information for Community Care Licensing and the state Ombudsman office.

Based on records review, RP was also provided with documentation of R1’s daily behavior log from dates between “June 12” until “7/30/19” together with the eviction notice. The behavior log consisted of caregiver’s observation at every shift (AM, PM, NOC) when they helped R1 with ADLs. The behavior log noted days when resident was calm or not agitated but most days would describe resident to be "agitated" and/or “combative”, or that R1 would yell at the caregivers. The logs also noted two instances where R1 had an incident with the other residents at the facility.

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 ED Matt Zahodne.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

LIC9099 (FAS) - (06/04)

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