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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294191
Report Date: 12/16/2024
Date Signed: 12/16/2024 01:21:07 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
04/15/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240415164143
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:
12/16/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Staff, Melanie AblanTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff refused to take resident, who sustained a fracture, for immediate medical attention
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPA met with Staff, Melanie Ablan

On April 15, 2024, the Department received a complaint alleging Staff refused to take resident, who sustained a fracture, for immediate medical attention. It has been alleged, on April 9, 2024, facility staff stated that it is a waste of resources to call 911 and have the client transported to the ER because it is normal for the client to have swollen legs.

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

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
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 2
Control Number 26-AS-20240415164143
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: 12/16/2024
NARRATIVE
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On April 15, 2024, the Department received an incident report (IR) regarding R1. The incident report stated on April 9, 2024, R1 arrived in a wheelchair to the day program. While assisting R1 from his/her wheelchair, staff noticed R1’s legs were swollen and was experiencing pain. Program Coordinator (PC) called R1’s responsible party and informed him/her of the observations. PC let R1’s responsible party that 911 would be called for R1. When 911 arrived R1 was still having a hard time ambulating and when placed on gurney, PC noticed his/her left leg had a quarter size bruise and fresh blood dripping down his/her leg.

Later in the day PC spoke with Kingdom Hearts Staff S1 regarding R1’s swollen legs. S1 told PC it was normal for R1’s legs to be swollen and that it was a waste of resources to send R1 to the emergency room. PC told S1 it was different that day and R1 was complaining about pain.

On April 25, 2024, Licensing Program Analyst Manuel Monter interviewed staff S1. S1 stated he/she mentioned to the day program that he/she didn’t want R1 transferred unnecessarily to the hospital and use resources unnecessarily. S1 stated a few weeks ago, the day program had R1 sent to the hospital. S1 stated after he/she was sent there, the resident returned with no issue. S1 stated he/she told the day program it was their call because they can see the resident in front of them.

On December 4, 2024, Licensing Program Analyst Manuel Monter interviewed Day Program ADM (DADM) and Day Program Staff (DS1 & DS2). DS1 and DS2 stated when R1 had arrived to the day program, they observed R1 with swollen legs and R1 had expressed pain on his/her legs. DS1 contacted 911 and also called R1’s responsible party to inform him/her R1 was being sent to the hospital. DADM and S1 stated the phone call with Kingdom Hearts Care home staff, S1, was in the afternoon, after R1 was already sent to the hospital.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED. Although it is a fact that S1 did in fact say, “ it was a waste of resources to call 911 and have the client transported to the ER because it is normal for the client to have swollen legs”, based on interviews conducted, Resident R1 was in the care of the day program when 911 was contacted, and the phone call with the Care Home staff S1 was conducted after R1 had already been hospitalized.

Page 2 Out of 2. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2