435294286-10-31-2024-26-AS-KHOS-DAXQE8-20241112110555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294286
Report Date: 10/31/2024
Date Signed: 10/31/2024 04:48:58 PM

Unsubstantiated

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
01/11/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20240111153835

FACILITY NAME:	WILLIE CARE HOME II		FACILITY NUMBER:	435294286
ADMINISTRATOR:	ZHAO, WUSHENG		FACILITY TYPE:	740
ADDRESS:	1136 SOUTH MARY AVENUE		TELEPHONE:	(408) 749-8758
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	6	CENSUS: 5	DATE:	10/31/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Guili Xu		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Facility and staff did not treat residents with dignity and respect
Facility did not provide the appropriate variety of food in a timely manner
Facility did not provide adequate basic services to residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Administrator (ADM) Guili Xu.

On 1/11/2024, the Department received a complaint with the above allegations.

On 1/19/2024, the Department conducted an initial investigation visit.

LPA interviewed ADM, 2 staff, and residents.

LPA requested Roster of residents, LIC500 Personnel Report, residents' physician reports, Appraisal Needs and Service Plan, and food menu.

Continue on LIC9099-C. page 1 of 5.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

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 8

Control Number 26-AS-20240111153835

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: WILLIE CARE HOME II	FACILITY NUMBER: 435294286
	VISIT DATE: 10/31/2024

NARRATIVE

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Facility and staff did not treat residents with dignity and respect:
The Allegation is that staff did not treat resident R1 with dignity and respect when staff changed the diapers and clothing for R1.

On 1/17/2024, LPA interviewed R1's family member (FM). FM stated in September 2023, a male caregiver S1 was rude and rough to R1 when changing R1's diaper and clothing.

On 1/19/2024, LPA interviewed resident R1. R1 stated a female caregiver S2 treated him/her rude. LPA interviewed the other 5 residents. 3 Out of 5 residents did not have any complaint against the facility staff.

LPA interviewed staff S2. S2 denied he/she was rude to resident R1.

LPA interviewed ADM. ADM denied staff abused residents.

On 10/17/2024, LPA interviewed Administrator (ADM). ADM stated staff S1 worked for NOC shift from Monday to Friday. ADM stated R1's family member (FM) reported to him/her that S1 was rude to R1 when changing R1's diapers and clothing even though was not intentionally. ADM stated he/she interviewed S1 and S1 denied he/she treated R1 rude and rough. ADM stated he/she decided to let S1 go within S1's first two month's working in the facility. ADM stated it was not an staff abusing resident incident. ADM stated he/she wants to maintain the quality of service to residents. ADM stated after S1's incident, he/she did not receive any report that staff treat residents rude.

LPA interviewed 2 staff. Both denied they treat residents rude.

LPA interviewed 5 residents. 3 Out of 5 residents stated they did not see or hear any incident that staff treat residents rude.

Based on the review of the Law Enforcement Task Report dated 1/11/2024, R1 stated the facility staff were trying their best not to harm R1 when staff were working with R1. The report states R1 was not a victim of physical abuse or neglect.
Continue on LIC9099-C. Page 2 of 5.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 26-AS-20240111153835

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: WILLIE CARE HOME II	FACILITY NUMBER: 435294286
	VISIT DATE: 10/31/2024

NARRATIVE

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Based on the interviews and records reviewed, there is no evidence to indicate that facility and staff did not treat residents with dignity and respect.

Facility did not provide the appropriate variety of food in a timely manner:
The allegation is that the facility did not provide appropriate variety of food in a timely manner to resident R1. R1's dinner was offered around 3:30PM to 4:30PM . Family member claimed it was too early for dinner.

On 1/19/2024, LPA interviewed Administrator (ADM). ADM stated the facility breakfast is from 7:00AM to 9:00PM, lunch is from 11:00AM to 1:00PM, and dinner is from 4:00PM to 6:00PM. ADM stated after dinner, the facility staff need to clean the kitchen, help residents for showers, administer medications to residents, and prepare residents to go to sleep. ADM stated some family members might think the dinner is offered too early, but the facility staff are very busy after dinner. The dinners are scheduled from 4:00PM to 6:00PM.

ADM stated resident R1 does not have teeth and R1 eats meals at bed. ADM stated the facility has some limits to offer the food for R1. ADM stated R1 does not eat the food he/she does not like.

LPA interviewed resident R1. R1 stated one day, he/she was offered sandwiches for the whole day.

LPA interviewed other 5 residents. 3 out of 5 residents did not have any complaint for the facility meals.

On 10/17/2024, LPA interviewed ADM. ADM stated the facility offers variety of food for meals and provides the facility food menu to LPA.

LPA interviewed staff S3. S3 stated he/she is a cook. S3 stated she cooks variety of food for meals. S3 stated resident R1 does not have teeth and eats meals at bed. S3 stated he/she offered different food for R1, but R1 most time refused. S3 stated one time he/she prepared a very good Thanksgiving dinner for R1, but R1 refused it. S3 stated most of time R1 accepts sandwich. S3 stated he/she provided sandwiches with different flavor to R1. S3 stated the facility breakfast is 7:00AM to 9:00AM, lunch is from 11:00AM to 1:00PM, and dinner is from 4:00PM to 6:00PM.

Continue on LIC9099-C. Page 3 of 5.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 26-AS-20240111153835

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: WILLIE CARE HOME II	FACILITY NUMBER: 435294286
	VISIT DATE: 10/31/2024

NARRATIVE

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LPA interviewed 5 residents. 3 Out of 5 residents stated they likes the facility food and no complaint about the facility meals.

During LPA's visit of the facility, LPA observed residents were served the lunches. LPA observed food supplies with a variety of vegetables, meats, protein, grains, and juice.

Based on the review of the Law Enforcement Task Report dated 1/11/2024, the food offered to R1 was observed with different items and sufficient by R1.

Based on the observation, interview, and records reviewed, there is no evidence to indicate the facility did not provide the appropriate variety of food in a timely manner to R1.

Facility did not provide adequate basic services to residents:
The allegation is that the facility did not provide basic care and service to resident R1.

On 1/19/2024, LPA interviewed resident R1. R1 stated the facility staff come to check his/her condition every day, but he/she was unable to confirm how often. R1 stated the facility staff clean his/her room but was unable to confirm how often. R1 stated the facility staff check/change his/her diaper but he/she was unable to confirm how often. LPA observed R1 has a pendant call, LPA pressed the pendant call and observed staff came within 2 minutes. R1 stated he/she has bed bath every day with staff's help.

R1 stated one day he/she had a deflated mattress.

LPA interviewed ADM. ADM stated the staff check resident every two hours. ADM stated residents can press call button to ask for help immediately. ADM stated resident R1 had an air inflated mattress. ADM stated that day PG&E had a power outrage and was unable to inflate R1's mattress.

On 10/17/2024, LPA interviewed staff S3. S3 stated staff check residents every two hours. Staff change resident diaper every two hours. Staff clean resident room every day. S3 stated for R1's deflated mattress issue, the facility staff offered to transfer R1 to a regular mattress but R1 refused.

Continue on LIC9099-C. Page 4 of 5.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 8

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
01/11/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20240111153835

FACILITY NAME:	WILLIE CARE HOME II		FACILITY NUMBER:	435294286
ADMINISTRATOR:	ZHAO, WUSHENG		FACILITY TYPE:	740
ADDRESS:	1136 SOUTH MARY AVENUE		TELEPHONE:	(408) 749-8758
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	6	CENSUS: 5	DATE:	10/31/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Guili Xu		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Facility did not keep the facility clean and free of flies and other insects.
Staff did not administer medication in a timely manner.

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

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 8

Control Number 26-AS-20240111153835

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: WILLIE CARE HOME II	FACILITY NUMBER: 435294286
	VISIT DATE: 10/31/2024

NARRATIVE

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Facility did not keep the facility clean and free of flies and other insects:
The allegation is that on 7/13/2023, resident R1's room was found a lot of ants.

On 1/19/2023, LPA interviewed resident R1. R1 stated he/she found ants in the room when the first day he/she moved in the facility. R1 stated staff cleaned the room and got rid of the ants immediately. R1 stated after that day, he/she did not see any ants in the room.

LPA toured all 6 residents rooms. LPA did not observe any ants or other insects in all the resident rooms.

LPA interviewed other 5 residents. 3 Out of 5 residents stated they do not any complaint regarding the facility environment. 3 Out of 5 residents stated there is no ant or inspects in the resident rooms.

On 10/17/2024, LPA interviewed 2 staff. Both stated the facility staff clean resident room every day.

LPA interviewed ADM. ADM stated R1 moved in the facility in June 2023.

LPA toured the facility including 6 resident bedrooms, LPA did not observe any ant or inspect in the resident rooms or in the facility.

Based on the review of the Law Enforcement Task Report dated 1/11/2024, resident R1's room was observed in sanitary condition and well maintained. R1 was observed to be in good health condition, and was not in distress or upset. There is no evidence that on 7/13/2023, R1's room had a lot of ants.

Based on the interviews, observation, and record reviewed, resident R1's room was in sanitary condition and well maintained.

Staff did not administer medication in a timely manner:
The allegation is resident R1 was not administered medication for 4 days.

On 1/19/2023, LPA interviewed resident R1. R1 stated the facility staff administer medications to him/her on time.
Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 26-AS-20240111153835

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: WILLIE CARE HOME II	FACILITY NUMBER: 435294286
	VISIT DATE: 10/31/2024

NARRATIVE

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On 10/17/2024, LPA interviewed ADM. ADM stated the facility staff only administer doctor prescription medications or doctor order medication to residents.

LPA interviewed 2 staff . Both stated they administer medications to residents based on doctor prescription or doctor order. Both stated they administer medications to residents and watch residents to finish the medications and they leave the resident room.

LPA interviewed 5 residents. 3 out of 5 residents stated the staff give them medications every day.

Based on the review of the Law Enforcement Task Report dated on 1/11/2024, R1 stated the facility staff are very careful with the medications he/she requires and he/she is not allowed to take any other medication that are not prescribed by doctor.

Based on the interviews and record reviewed, there is no evidence to indicate Staff did not administer medication in a timely manner:

The Department has investigated the above allegations. Based on the investigation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. This report was provided to review and for signature. A copy of this report was provided to ADM.

Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 26-AS-20240111153835

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: WILLIE CARE HOME II	FACILITY NUMBER: 435294286
	VISIT DATE: 10/31/2024

NARRATIVE

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LPA interviewed 5 residents. 3 Out of 5 residents stated they don't have any complaint against the facility.

Based on the review of the Law Enforcement Task Report dated 1/11/2024, R1 stated staff takes good care of him/her and staff checked him/her occasionally, and R1 was observed has call button to call for help.

Based on the interview, observation, and records reviewed, there is no evidence to indicate facility did not provide adequate basic services to resident R1.

Based on documents reviewed, and interviews conducted, the Department found that the above allegations are 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 allegation did or did not occur.

No citations noted for today’s visit. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of this report was provided to ADM.

Page 5 of 5.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 8