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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445200583
Report Date: 12/21/2024
Date Signed: 12/21/2024 09:19:15 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
01/26/2024 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20240126131739
FACILITY NAME:WRC-2FACILITY NUMBER:
445200583
ADMINISTRATOR:MEGAN C. MILLERFACILITY TYPE:
740
ADDRESS:174 WILLOWBROOK DRIVETELEPHONE:
(831) 336-5196
CITY:BEN LOMONDSTATE: CAZIP CODE:
95005
CAPACITY:6CENSUS: 6DATE:
12/21/2024
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Staff, Claudia NietoTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Staff will not allow resident to return to the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Staff, Claudia Nieto and stated the purpose of today’s visit. Administrator was not available during today's visit.

On 1/26/2024, the Department received a complaint with the above allegations. On 1/26/2024, the Department conducted an initial investigation at the facility. It was alleged the facility staff stated resident (R1) cannot return to the facility from the hospital because the resident needs a higher level of care.

On 1/16/2024, R1 went to the hospital and was assessed at the hospital. The hospital staff determined R1 was not appropriate for hospital admission and notified facility Administrator (ADM) Megan Miller. ADM stated R1 could not return to the facility due to R1 requiring higher level of care.

Continuation on LIC 9099-C, Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
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-20240126131739
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: WRC-2
FACILITY NUMBER: 445200583
VISIT DATE: 12/21/2024
NARRATIVE
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Page 2 of 2.

On 1/26/2024, LPA Rai interviewed ADM and Staff S1. ADM stated R1 was taken to the hospital via ambulance due to R1 not able to ambulate to the bed in the evening. ADM stated she was working with the hospital to assess if the resident was diagnosed with Dementia. ADM stated the facility staff were looking for skilled nursing placement before resident went to the hospital due to a decline in R1’s health and increased confusion. ADM stated R1 was brought back to the facility, and they are working to obtain a referral with the neurologist for a consultation. ADM notified the hospital social worker stating R1’s bed is open and R1 was not being evicted at this time, but the resident needed higher level of care such as skilled nursing as order my R1’s physician.

Based on record review, R1 had an appointment on 1/12/2024 with Physician’s Assistant who recommended facility to pursue skilled nursing facility placement since the reason for the appointment was “confusion, falling and wandering”. Based on review of R1’s hospital discharge notes on 1/16/2024, R1 was diagnosed with neurocognitive disorder without behavioral disturbance.

During visit 1/16/2024, R1 was admitted back to the facility and ADM stated they are working with R1’s primary care physician to find a facility to be able to care for residents with Dementia. ADM stated facility had not issued a formal eviction notice.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Staff, Claudia Nieto and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2