435294258-2-25-2026-26-AS-CKAI-DS42YE-20260311174836

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294258
Report Date: 02/25/2026
Date Signed: 02/25/2026 09:49:01 AM

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
07/16/2025 and conducted by Evaluator Marcela Yanez

COMPLAINT CONTROL NUMBER: 26-AS-20250716141943

FACILITY NAME:	BECK CARE HOME		FACILITY NUMBER:	435294258
ADMINISTRATOR:	ZHANG, YU & LUO, XI-HUA		FACILITY TYPE:	740
ADDRESS:	1681 BECK DRIVE		TELEPHONE:	(408) 866-7858
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95130
CAPACITY:	6	CENSUS: 4	DATE:	02/25/2026
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Xi-Hua Luo		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

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Neglect/Lack of Supervision: Facilty staff changed resident's catheter causing serious injury wherein resident had dark blood and discomfort

INVESTIGATION FINDINGS:

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On February 25, 2026 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint investigation visit to deliver findings and met with Xi-Hua Luo, Administrator (ADM). LPA announced the purpose of the visit.

On July 16, 2025 the department received a complaint with the allegation for Neglect/Lack of Supervision: Facility staff changed resident's catheter causing serious injury wherein resident had dark blood and discomfort.

On July 18/2025 Licensing Program Analyst (LPA) Marcela Yanez conducted a 10-day complaint investigation visit and obtained pertinent documents.

page 1 of 2

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

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 7

Control Number 26-AS-20250716141943

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: BECK CARE HOME	FACILITY NUMBER: 435294258
	VISIT DATE: 02/25/2026

NARRATIVE

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During the investigation the department interviewed 2 staff (S1-S2) and Administrator (ADM)

On 07/07/25 Resident (R1) was receiving hospice services and had had an issue with his/her catheter. R1 was found by staff S1 nat 5:00pm with urine and blood on his/her bedding. Staff (S1) stated he/she called ADM to inform what was going on. ADM arrived shortly after and observed R1 in pain and grimacing and the resident had no urine output for about 8 hours. ADM, who is a Licensed Registered Nurse , stated that the caregiver had called the Hospice nurse and informed them what was going on and that the hospice nurse was on their way to the facility. ADM stated it had been almost an hour since the hospice nurse had been notified and that the resident had a distended abdomen and pain in which the ADM took it upon him/herself to remove the catheter placement and reinsert the suprapubic catheter.

Witness (W1) arrived after ADM had changed the catheter and decided to call the ambulance. R1 was sent to the hospital where R1 was admitted with a chief complaint of blood in the urine.

Based on R1s medical records during the hospital visit a Computed Tomography, (CT) scan was done and the results of (CT) indicated catheter was in good position and clinically draining well with no need for bladder irrigation. R1 condition was stable and returned to the facility the same day.

On July 12. 2025 R1 passed away, based on record review R1s cause of death was not related his/her catheter care.

The department has investigated the complaint allegations listed. Based on interviews and review of records, the department has found that the complaint allegation is unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No deficiencies cited during today's visit per California Code of Regulations, Title 22.

An exit interview was conducted with the Licensee and a signed copy of this report was provided

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 7

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
07/16/2025 and conducted by Evaluator Marcela Yanez

COMPLAINT CONTROL NUMBER: 26-AS-20250716141943

FACILITY NAME:	BECK CARE HOME		FACILITY NUMBER:	435294258
ADMINISTRATOR:	ZHANG, YU & LUO, XI-HUA		FACILITY TYPE:	740
ADDRESS:	1681 BECK DRIVE		TELEPHONE:	(408) 866-7858
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95130
CAPACITY:	6	CENSUS: 4	DATE:	02/25/2026
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Xi-Hua Lou		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

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9

Facility staff did not seek timely medical attention when resident had issues with catheter.
Facility staff did not notify resident's responsible party regarding change of resident's condition.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
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10
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13

On February 25, 2026 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint investigation visit to deliver findings and met with Xi-Hua Luo, Administrator (ADM). LPA announced the purpose of the visit.

On July 16, 2025 the department received a complaint with the allegation of Facility staff did not seek timely medical attention when resident had issues with catheter. Facility staff did not notify resident's responsible party regarding change of resident's condition.

On July 18, 2025 Licensing Program Analyst (LPA) Marcela Yanez conducted a 10-day complaint investigation visit and obtained pertinent documents.

Page 1 of 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 26-AS-20250716141943

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: BECK CARE HOME	FACILITY NUMBER: 435294258
	VISIT DATE: 02/25/2026

NARRATIVE

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During the investigation the department interviewed 2 staff (S1-S2) and Administrator.

On 07/07/25 Resident (R1) was receiving hospice services and had had an issue with his/her catheter. R1 was found by staff S1 nat 5:00pm with urine and blood on his/her bedding. Staff (S1) stated he/she called ADM to inform what was going on. ADM arrived shortly after and observed R1 in pain and grimacing and the resident had no urine output for about 8 hours. ADM, who is a Licensed Registered Nurse , stated that the caregiver had called the Hospice nurse and informed them what was going on and that the hospice nurse was on their way to the facility. ADM stated it had been almost an hour since the hospice nurse had been notified and that the resident had a distended abdomen and was in pain in which the ADM took it upon him/herself to remove the catheter placement and reinsert the suprapubic catheter.

ADM stated that staff had called hospice nurse and informed him/her of resident’s condition. ADM stated that anytime a resident is on hospice services the staff inform the hospice nurse before calling 911. ADM stated that when a resident moves into the facility the POA is notified regarding any resident health update or financial concern. ADM stated that POA stated to please contact Care Manager regarding any health concerns due to Care Manager being located closer to the facility. At the time of incident staff notified Care Manager of residents condition and was instructed to call Hospice Nurse.

Based on interviews and record review the incident that occurred on July 7 2025, the facility followed hospice procedure and called hospice nurse of R1's catheter leaking blood and urine. ADM stated that the staff called Care Manager who arrived shortly after the catheter was reinserted.

Based on interviews, records review and observations, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited during today's visit per California Code of Regulations, Title 22.

An exit interview was conducted with the Licensee and a signed copy of this report was provided

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 7

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
07/16/2025 and conducted by Evaluator Marcela Yanez

COMPLAINT CONTROL NUMBER: 26-AS-20250716141943

FACILITY NAME:	BECK CARE HOME		FACILITY NUMBER:	435294258
ADMINISTRATOR:	ZHANG, YU & LUO, XI-HUA		FACILITY TYPE:	740
ADDRESS:	1681 BECK DRIVE		TELEPHONE:	(408) 866-7858
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95130
CAPACITY:	6	CENSUS: 4	DATE:	02/25/2026
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Xi-Hua Luo		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff changed resident's catheter without doctor's orders

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Marcela Yanez conducted a complaint investigation visit to deliver findings. LPA announced the purpose of the visit and met with Xi-Hua Luo, Administrator.

On July 16, 2025 the department received a complaint with the allegation of Facility staff changed resident's catheter without doctor's orders.

On July 18, 2025 Licensing Program Analyst (LPA) Marcela Yanez conducted a 10-day complaint investigation visit and obtained pertinent documents.

During the investigation the department interviewed 2 staff (S1-S2) and Administrator (ADM).

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 26-AS-20250716141943

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: BECK CARE HOME	FACILITY NUMBER: 435294258
	VISIT DATE: 02/25/2026

NARRATIVE

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On 07/07/25 Resident (R1) was receiving hospice services and had had an issue with his/her catheter. R1 was found by staff S1 at 5:00pm with urine and blood on his/her bedding. Staff (S1) stated he/she called ADM to inform what was going on. ADM arrived shortly after and observed R1 in pain and grimacing and the resident had no urine output for about 8 hours. ADM, who is a Licensed Registered Nurse , stated that the caregiver had called the Hospice nurse and informed them what was going on and that the hospice nurse was on their way to the facility. ADM stated it had been almost an hour since the hospice nurse had been notified and that the resident had a distended abdomen and pain in which the ADM took it upon him/herself to remove the catheter placement and reinsert the suprapubic catheter.

W2 stated that the resident moved into the facility on March 1, 2025 and had a catheter that was being cared for by home health. ADM provided a copy of R1s Hospice agreement dated April 7, 2025 stating that Hospice services would oversee changing the catheter once a month. ADM stated she was aware of the agreement.
ADM felt that the resident was in pain and discomfort and felt it was necessary to change the catheter because of no urine output. ADM did not have a doctor’s written order stating he/she was authorized to change R1s catheter.

R1 was under a Hospice service agreement that states Hospice services will be provided by a hospice nurse. Hospice nurse was notified by staff at the facility and did not arrive till shortly after R1s catheter was already changed by the ADM.

R1s was sent to the hospital to check if the catheter was properly placed and there was no injury from the ADM changing the catheter.

Documentation stated R1s catheter was properly placed and clinically draining well. Although ADM is a Licensed Registered Nurse he/she did not follow the signed Hospice Agreement dated February 25, 2026.

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

Citations noted today. Please see LIC9099-D. Exit interview was conducted with Xi-Ha Luo, ADM. A copy of the report and appeals rights were provided.

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 26-AS-20250716141943

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: BECK CARE HOME	FACILITY NUMBER: 435294258
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/25/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/26/2026 Section Cited CCR 87623(a)(1)(B)	1 2 3 4 5 6 7	87623 In Dwelling Catheter (B) A catheter shall only be inserted and removed by an appropriately skilled professional under physician's orders. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	ADM stated will submit a written plan of action understanding the regulation and will follow hospice care plan for residents requiring services from hospice nurse by POC due date. Administrator agreed and understood.
	8 9 10 11 12 13 14	Based on record review and interview, ADM changed the Resident R1s catheter without a doctors order and did not follow hospice care plan dated 04/07/25 in which hospice services would change catheter every month which poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

LIC9099 (FAS) - (06/04)

Page: 7 of 7