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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294191
Report Date: 06/07/2024
Date Signed: 06/07/2024 12:24:42 PM

Substantiated


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
04/16/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240416133846
FACILITY NAME:KINGDOM HEARTS CARE HOMEFACILITY NUMBER:
435294191
ADMINISTRATOR:ABLAN, ANABELLEFACILITY TYPE:
740
ADDRESS:3664 BRIGADOON WAYTELEPHONE:
(408) 223-3305
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 5DATE:
06/07/2024
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Administrator Anabelle AblanTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Facility is not administering Residents medications per physicians orders
INVESTIGATION FINDINGS:
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On April 16, 2024, the Department received a complaint alleging facility is not administering Residents medications per physicians’ orders.

On April 25, 2024, Licensing Program Analyst Manuel Monter conducted an unannounced complaint investigation visit.

On April 25, 2024, Licensing Program Analyst Manuel Monter randomly audited 3 residents’ medications. LPA audited residents medications by reviewing the medication container/bottle and cross referencing them with the Centrally Stored Medication Log.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
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 5
Control Number 26-AS-20240416133846
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: KINGDOM HEARTS CARE HOME
FACILITY NUMBER: 435294191
VISIT DATE: 06/07/2024
NARRATIVE
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While reviewing resident R1's medications, LPA and ADM discovered a discrepancy. Medication #1 has a start date of March 12, 2024. The instructions are 3 tablets, 3x a day, which would result to 9 tablets a day total. The total pill count for this medication is 900. The Centrally Stored Medication Log and the ADM stated the facility has administered the medication for 44 days since March 12. (44 days x 9 pills=396 + the 3 pills that have been given this morning=399). ADM counted the remaining number of pills in the container, which totaled 556 pills. (556+399=955, A total of 55 excess pills.) ADM acknowledged that there have been instances where 1 pill was given instead of 3 and she has informed R1's responsible party.

On June 7, 2024, LPA interviewed staff S1 and S2. S1 states he/she doesn't know why there was an excess of 55 pills. S2 stated he/she did miss giving out R1's medication #1 sometime for the month April, in the afternoon pill passes.

LPA interviewed facility ADM. ADM stated R1 did not have any hospitalization's since R1 moved into the facility. ADM stated R1 has not had any overnight stays since he/she moved into the facility.

Based on a review of R1's physicians report, dated September 18, 2023. R1 cannot manage his/her own medication.

Based on a file review, there are no incident reports regarding R1 stating he/she had any hospitalization's or medication errors since R1's admission.

Based on interviews and evidenced reviewed the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with Administrator Anabelle Ablan and a copy of the report was provided. Appeal Rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20240416133846
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: KINGDOM HEARTS CARE HOME
FACILITY NUMBER: 435294191
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self administered medications as needed.

This requirement was not met as evidence by:
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ADM stated she will be conducting a medication training for her staff. ADM stated she will document the staff who attend the training and send the documentation to LPA by POC date.
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Based on record review and interviews conducted, R1’s medications had an excess of 55 pills. ADM acknowledged that there have been instances where 1 pill was given instead of 3 pills. This poses/posed a potential health, safety or personal rights risk to persons in care.
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 ADM stated she will send the plan of correction by POC date June 8, 2024.
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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: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/16/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240416133846

FACILITY NAME:KINGDOM HEARTS CARE HOMEFACILITY NUMBER:
435294191
ADMINISTRATOR:ABLAN, ANABELLEFACILITY TYPE:
740
ADDRESS:3664 BRIGADOON WAYTELEPHONE:
(408) 223-3305
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 5DATE:
06/07/2024
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Administrator Anabelle AblanTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Facility staff did not respond in a timely manner to a residents fall.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Administrator Anabelle Ablan.

On April 16, 2024, the Department received a complaint alleging facility staff did not respond in a timely manner to a residents fall. It has been alleged resident R1 sustained a fall on an unspecified date, and facility staff did not respond in a timely manner.

On April 25, 2024, Licensing Program Analyst Manuel Monter interviewed 5 Out of 5 staff and the facility administrator. 5 Out 5 staff stated resident R1 has not had a fall. ADM stated resident R1 has not had a fall since he/she moved in.

Page 1 Out of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20240416133846
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: KINGDOM HEARTS CARE HOME
FACILITY NUMBER: 435294191
VISIT DATE: 06/07/2024
NARRATIVE
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LPA Monter interviewed residents R1-R5. Resident R1 stated he/she had a fall but did not give an answer to when or where he/she had a fall. R2 and R3 stated resident R1 has not had a fall. Resident R4 stated he/she did not want to be interviewed. Resident R5 did not respond to LPA’s questions and is nonverbal.

On May 7, 2024, LPA interviewed Witness W1. W1 stated he/she visits the facility weekly to see R1. W1 stated he/she has not observed any signs of R1 sustaining a fall since R1 moved into the facility.

On June 7, 2024, LPA interviewed ADM. ADM stated R1 does leans forward in general when he/she seated in the wheel chair. ADM stated R1 will also lean forward when eating at the kitchen table or using his/her Ipad. ADM stated staff is present in the facility and have not observed R1 fall.

A review of R1's Admission Agreement shows, R1 moved into the facility on September 23, 2023.

A review of R1's physician's report, dated September 18, 2023, states R1 is non-ambulatory, based on physical condition. The form states R1 will not ask for help and attempts walking.

A review of R1's Pre-Placement Appraisal, dated September 23, 2023, states R1 uses a wheel chair, but cannot get in and out unassisted.

Based on a File Review, there are no incident reports regarding R1 stating he/she had any hospitalization's or falls since admission.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5