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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294328
Report Date: 05/30/2025
Date Signed: 05/30/2025 04:47:39 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
03/05/2025 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20250305170352
FACILITY NAME:VILLA FONTANAFACILITY NUMBER:
435294328
ADMINISTRATOR:DUEWEL, MA. FELICITAS V.FACILITY TYPE:
740
ADDRESS:5555 PROSPECT ROADTELEPHONE:
(408) 255-5555
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:104CENSUS: 87DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Marife DurewelTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Resident sustained a fracture due to lack of care from staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Marife Durewel.

On 3/5/2025, the Department received a complaint with the allegation that resident sustained a fracture due to lack of care from staff.

On 3/6/2025 and 4/4/2025, the Department conducted investigation visits.

LPA requested resident roster and LIC500 Personnel Report. LPA requested the physician reports, appraisal needs and service plans, progress notes of resident and incident reports.

LPA interviewed ED and 5 staff. LPA toured resident R1's room, interviewed R1's private caregiver and R1.
Continue on LIC9099-C. PAge 1 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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 3
Control Number 26-AS-20250305170352
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: VILLA FONTANA
FACILITY NUMBER: 435294328
VISIT DATE: 05/30/2025
NARRATIVE
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The allegation is that resident sustained fracture due to staff lack of supervision.

On 4/4/2025 and 5/12/2025, LPA interviewed Executive Director (ED) Marife Durewel. ED stated on 2/23/2025, after dinner, around 5:45PM, resident R1 was found on the floor in his/her room. ED stated R1 stated he/she fell when tried to get his/her back bag. 911 was called by staff and R1 was sent to hospital. ED stated on 2/24/2025, around 2:20AM R1 returned to the facility. ED stated the facility contacted R1's responsible party to have 1:1 24x7 caregiver for R1 after R1 returned to the facility. ED stated the facility has a caregiver sits on a chair by the door of R1's room to monitor R1 and lets R1's door remain open after R1 returned back to the facility.

ED stated on 2/27/2025, at 6:30AM, R1 was found in the bed in his/her room. ED stated on 2/27/2025, around 6:45AM, R1 was found on the floor in his/her room. 911 was called immediately and R1 was sent to hospital. On 3/5/2025, R1 returned to the facility. ED stated R1 has 1:1 24 x 7 caregiver staring from 3/5/2025.

On 4/4/2025, LPA interviewed Health and Wellness Director (HWD). HWD stated the facility contacted resident R1's responsible party to suggest R1 to have a 1:1 24 X 7 caregiver after 2/23/2025. HWD stated R1's responsible party confirmed R1 to have 1:1 24 X 7 caregiver starting 3/5/2025.

LPA interviewed staff S1. S1 stated after 2/23/2025, the door of R1's bedroom is remained open, and there is a caregiver sits on the chair by the door of R1's room to monitor R1 when R1 is in the room.

LPA interviewed staff S2. S2 stated on 2/27/2025, around 6:30AM a NOC shift caregiver told him/her that he/she just checked R1 and R1 was in the bed.

LPA interviewed R1's 1:1 private caregiver (PC1). PC1 stated he/she works from 8:00AM - 8:00PM every day and another 1:1 private caregiver works from 8:00PM - 8:00AM every day. LPA observed a caregiver sat on the chair by the door of R1's room.

Continue on LIC9099-C. Page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20250305170352
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: VILLA FONTANA
FACILITY NUMBER: 435294328
VISIT DATE: 05/30/2025
NARRATIVE
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On 5/12/2025, LPA interviewed a Med Tech (MT1). MT1 stated on 2/27/2025, around 6:30AM, a caregiver (S2) reported to him/her that he/she checked R1 on 2/27/2025 around 6:00AM and R1 was observed in the bed. MT1 stated on 2/27/2025 around 6:30AM he/she saw R1 was in the bed.

LPA interviewed a Med Tech (MT2). MT2 stated on 2/27/2025,a round 6:30AM, he/she saw R1 was in the bed. MT2 stated on 2/27/2025, around 6:45AM, he/she saw R1 was on the floor in his/her room. MT2 stated he/she called 911 and nurse, and R1 was sent to hospital.

LPA interviewed resident R1 in his/her room. R1 stated for his/her last fall incident on 2/27/2025, he/she got up from bed around 6:40AM. R1 stated he/she just wanted to walk in the room for exercise and fell on the floor. R1 stated staff came in to help him/her immediately.

LPA observed R1's 1:1 caregiver in R1's room helping R1. LPA observed a caregiver sat on the chair by the door of R1's room.

Based on the review of R1's Appraisal needs and service plan dated 11/10/2024, R1 is able to ambulate with standby assist. R1 uses wheelchair for mobility.

Based on the interview and observation, the facility lets the door of R1's room open and has a caregiver sitting on the chair by the door of R1's room to monitor R1 after 2/23/2025. The facility suggested to R1's responsible party to have 1:1 24 X 7 private caregiver for R1 after 2/23/2025. On 2/27/2025 around 6:30AM, 2 staff observed R1 was in the bed. Around 6:40AM, R1 tired to get up from bed by self and fell. Around 6:45AM, R1 was found by staff. Staff called 911 immediately and R1 was sent to hospital.

The department has investigated the above allegation. Based on the observations, 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.

No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ED. A copy of this report was provided to ED.
Page 3 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3