445202356-1-9-2025-26-AS-KHOS-DD4P9D-20250120100658

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202356
Report Date: 01/09/2025
Date Signed: 01/09/2025 11:45:05 AM

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
08/07/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230807105035

FACILITY NAME:	MONTECITO MANOR		FACILITY NUMBER:	445202356
ADMINISTRATOR:	JOLENE SICLEY		FACILITY TYPE:	740
ADDRESS:	311 MONTECITO AVE.		TELEPHONE:	(831) 724-3055
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY:	85	CENSUS: 54	DATE:	01/09/2025
		UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Ivonne Sanchez		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff did not ensure resident was regularly observed for changes in physical health condition
Staff did not seek medical attention for resident in a timely manner
Staff did not ensure record of centrally stored medications was complete
Staff do not provide water to residents

INVESTIGATION FINDINGS:

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On 1/9/2025, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Assistant Manager Ivonne Sanchez and LPA explained the purpose of the visit.

For the allegations of staff did not ensure resident (R1) was regularly observed for changes in physical health condition and staff did not seek medical attention for resident in a timely manner, reporting party (RP) stated that R1 had to be brought to the hospital and was found to have a UTI and was discharged. RP stated he/she visited R1 two days later, and R1 was acting different and was incapacitated again. RP stated 911 was called and R1 was again taken to the hospital. RP stated that they are concerned that staff saw R1s condition was worsening and never sought medical attention. RP stated that two weeks ago R1 was walking around and talking and now is unable to do those things because of the UTI.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230807105035

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: MONTECITO MANOR	FACILITY NUMBER: 445202356
	VISIT DATE: 01/09/2025

NARRATIVE

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LPA Marrufo was able to interview RP and it was shared that R1 actually had a bad UTI that was missed, so R1 was treated like he/she was totally out of their mind because R1 has mental illness. LPA Maruufo also interviewed three staff members. S1 mentioned that he/she hasn’t noticed anyone with urinary tract infection (UTI). S1 also has observed R1 to be wanting his/her family member (F1) to be with him/her 100% of the time. When F1 leaves, R1 moves his/her arms and legs and wants to smoke, but when her F1 comes, he/she doesn’t move his/her arms or legs. S2 shared that there has not really been anything S2 have seen where a resident has a change of condition. S2 has also observed that R1 acts weird when R1s family is here. When the family is not here, R1 can get out of bed and walk to the bathroom. R1 walks and goes to the toilet by himself/herself. R1 sometimes needs a little bit of help to clean. R1 puts his/her clothes together. S3 added that R1 went into the hospital about a week ago on a Tuesday or Wednesday. R1 went to the hospital for a UTI. Staff didn’t really observe any changes in R1 before that. R1 has always been a little slouched over all the time since R1 got here.

Based on records review, R1 was seen by P1, on 8/1/2023, who came to the facility to check on other residents. P1 is not R1s primary care physician. R1 was sent to the hospital due to P1s observation of R1 not looking right. R1 was sent and came back with a diagnosis of UTI. Last observation recorded in the progress notes was from 7/20/2023.

Regarding the allegation of staff did not ensure record of centrally stored medications was complete, RP stated that a staff (S1) said he/she is giving R1s antibiotic but when RP looked at the medication list last Friday (8/4/2023) the antibiotic was not listed.

LPA Donato reviewed the documents obtained by LPA Marrufo. It was shown in the Centrally Stored Medication and Destruction Records (CSMDR) that the start date of the antibiotic prescribed by the doctor was on 8/3/2023, it was filled by the pharmacy on 8/2/2023.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230807105035

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: MONTECITO MANOR	FACILITY NUMBER: 445202356
	VISIT DATE: 01/09/2025

NARRATIVE

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During the interview, S3 mentioned that R1 came back from the hospital on Thursday night or the week before. R1 was prescribed new medications. It was an antibiotic. R1 was given the medication according to the doctor’s prescription. S3 believes it was every 8 hours. It was a capsule.

For the allegation of staff do not provide water to residents, RP stated that R1 does not have access to water. RP stated when they showed up to visit, R1 was in bed and was unable to get up and did not have water anywhere within her reach. RP stated R1’s roommate also asked for water. RP stated there is a water dispenser out front but the residents cannot get to it if they can’t get out of bed.

During LPA Marrufo’s interview, when asked if they did you ask staff to provide R1 with water? RP answered that yes, that has been a constant thing every day that they are there. Even the other residents there have asked RP for glasses of water. It has been different since O1 have been there. They have water that they are bringing from the kitchen.

According to staff interviews, three out of three mentioned that staff provide enough water for residents. S1 mentioned that residents are provided water all the time, especially with R1. R1 asks for juice and water all the time. We give them water for all three meals per day. R1 would get more water. R1 would get water every 15-20 minutes. She asks for a lot of water. S2 also shared that for R1, he/she drinks a lot. R1 requests a lot of water. We give a pitcher by the bed. At meals, R1 would request for a large glass and put a straw because R1 would drop it all the time. R1 would drink 3 glasses of water with meals. There is a water station in the hallway. It is for all the residents.

Based on interviews & records reviews, 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 violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC9099 (FAS) - (06/04)

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