435294284-5-4-2021-26-AS-SYIP-C2QMX3-20210505095917

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294284
Report Date: 05/04/2021
Date Signed: 05/04/2021 04:52:25 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
05/07/2020 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200507094041

FACILITY NAME:	ST. MARY'S RESIDENTIAL CARE HOME II		FACILITY NUMBER:	435294284
ADMINISTRATOR:	ARIMAS, MARILUZ & MERLINO		FACILITY TYPE:	740
ADDRESS:	1265 SOCORRO AVENUE		TELEPHONE:	(408) 390-4931
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94089
CAPACITY:	6	CENSUS: 6	DATE:	05/04/2021
		UNANNOUNCED	TIME BEGAN:	03:11 PM
MET WITH:	Mariluz Arimas		TIME COMPLETED:	03:17 PM

ALLEGATION(S):

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9

Facility is not meeting the resident's needs

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent tele-complaint investigation to deliver the investigation finding. Due to current COVID-19 situation, LPA virtually met with Licensee Mariluz Arimas.

On 5/11/2020, an initial unannounced tele-investigation was conducted by LPA. LPA virtually toured the facility, interviewed 1 resident and 1 staff, and obtained 3 copies of Physician’s Report for Residential Care Facilities for the Elderly (LIC 602A), and 3 copies of Appraisal/Needs and Services Plan (LIC 625) for 3 residents. On 9/23/2020, a subsequent unannounced tele-investigation was conducted. LPA virtually toured the facility, and interviewed 5 residents. On 4/7/2021, LPA interviewed 2 staff on the phone, which included 1 staff who was previously interviewed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

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 4

Control Number 26-AS-20200507094041

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: ST. MARY'S RESIDENTIAL CARE HOME II	FACILITY NUMBER: 435294284
	VISIT DATE: 05/04/2021

NARRATIVE

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LPA reviewed R4’s and R5’s LIC 602A’s and LIC 625’s, and it was noted R4 and R5 could not bathe self, could not dress/groom self, could not care own toileting needs. Both R4 and R5 did not have dementia but had mild cognitive impairment. There was no skin breakdown noted.

Between 5/11/2020 and 9/23/2020, 6 residents were interviewed with 5 being successfully interviewed as 1 was not able to communicate. 5 out of 5 residents (including R1, R4, and R5) stated their needs were being met in the facility. LPA observed all 6 residents were clean and well kempt.

Between 5/11/2020 and 4/7/2021, 2 staff were interviewed. 2 out of 2 staff stated R1’s condition changed. Although there was no documentation, 2 out of 2 staff stated they made sure they turned R1 at least every 2 hours. Also, 2 out of 2 staff observed other caregivers turned R1 at least every 2 hours. No resident has wound or pressure injuries per staff.

Based on record review, the facility did not have fire clearance to retain a bedridden resident. An LIC 625 dated 5/5/2020 indicated the administrator observed R1 who could not hold any utensil or food anymore; R1 could not reposition self and staff had to reposition R1. There was no indication of skin breakdown. A medical note dated 6/19/2020 was noted to indicate that R1 needed higher level of care and be moved to a complete care facility.

Based on interviews, and records review, the department has determined that the allegation was UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

This report was emailed to Licensee for review and signature.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
05/07/2020 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200507094041

FACILITY NAME:	ST. MARY'S RESIDENTIAL CARE HOME II		FACILITY NUMBER:	435294284
ADMINISTRATOR:	ARIMAS, MARILUZ & MERLINO		FACILITY TYPE:	740
ADDRESS:	1265 SOCORRO AVENUE		TELEPHONE:	(408) 390-4931
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94089
CAPACITY:	6	CENSUS: 6	DATE:	05/04/2021
		UNANNOUNCED	TIME BEGAN:	03:11 PM
MET WITH:	Mariluz Arimas		TIME COMPLETED:	03:17 PM

ALLEGATION(S):

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8
9

Illegal eviction

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent tele-complaint investigation to deliver the investigation finding. Due to current COVID-19 situation, LPA virtually met with Licensee Mariluz Arimas.

On 5/11/2020, an initial unannounced tele-investigation was conducted by LPA. LPA virtually toured the facility, interviewed 1 resident and 1 staff, and obtained 3 copies of Physician’s Report for Residential Care Facilities for the Elderly (LIC 602A), and 3 copies of Appraisal/Needs and Services Plan (LIC 625). On 9/23/2020, a subsequent unannounced tele-investigation was conducted. LPA virtually toured the facility and interviewed 5 residents. On 4/7/2021, LPA interviewed 2 staff on the phone, including 1 staff who was previously interviewed.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

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 4

Control Number 26-AS-20200507094041

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: ST. MARY'S RESIDENTIAL CARE HOME II	FACILITY NUMBER: 435294284
	VISIT DATE: 05/04/2021

NARRATIVE

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Based on staff interview, R1 could not turn and reposition or feed self. R1 was interviewed but could not provide any information. R1 was observed not able to reposition oneself.

An LIC 625 of R1 dated 5/5/2020 revealed that R1 could not feed oneself. Staff had to feed R1. Also, R1 became bedbound and could not reposition without staff’s help. The Review of the facility’s fire clearance revealed that the facility did not have bedridden fire clearance. Thus, the facility was not a suitable placement for R1 to stay and cannot retain R1.

Based on records review, on 5/5/2020, the facility initially issued a 60-day courtesy notice to R1 and responsible party advising that the facility could not retain R1 who is bedridden so R1’s responsible party had more time to look for another placement. On 6/10/2020, an official 30-day eviction notice was issued to R1, responsible party, and the Department. On 6/19/2020, a medical note was issued to R1 indicated that R1 needed higher level of care and be moved to a complete care facility.

Based on the Department's interviews, observation, and records review, the allegation is UNFOUNDED, meaning it was false, could not have happened and/or is without a reasonable basis.

This report was emailed to Licensee for review and signature.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4