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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200608
Report Date: 06/07/2021
Date Signed: 06/07/2021 01:49:53 PM

Substantiated


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
04/14/2021 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20210414133152
FACILITY NAME:MAYFLOWER CARE HOMEFACILITY NUMBER:
435200608
ADMINISTRATOR:ESLAVA, ISABEL M.FACILITY TYPE:
740
ADDRESS:668 APACHE COURTTELEPHONE:
(408) 972-1999
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 6DATE:
06/07/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Isabel EslavaTIME COMPLETED:
01:48 PM
ALLEGATION(S):
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1. Facility did not follow resident's admission agreement.
2. Facility did not properly notify resident of rate increase.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Gladys Kuizon and Ryker Heberle conducted subsequent complaint investigation visit today to deliver investigation findings. LPAs met with licensee/administrator, Isabel Eslava.

On April 14, 2021, the Department received a complaint report alleging that the facility increased resident (R1)'s rate without proper notice and consequently, violated R1's admission agreement.

An initial complaint investigation tele-visit was conducted on April 22, 2021 and interviews were conducted. Administrator (S1) Isabel Eslava was interviewed regarding the allegations. S1 stated that resident (R1) was admitted to the facility on October 2, 2019 and was referred by Catholic Charities of Santa Clara County (CCSCC).

Continued, see LIC 9099-C, page 2 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
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 5
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
04/14/2021 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20210414133152

FACILITY NAME:MAYFLOWER CARE HOMEFACILITY NUMBER:
435200608
ADMINISTRATOR:ESLAVA, ISABEL M.FACILITY TYPE:
740
ADDRESS:668 APACHE COURTTELEPHONE:
(408) 972-1999
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 6DATE:
06/07/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Isabel EslavaTIME COMPLETED:
01:48 PM
ALLEGATION(S):
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9
Staff member threatened resident with eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Gladys Kuizon and Ryker Heberle conducted a subsequent complaint investigation visit today to deliver investigation findings. LPAs met with licensee/administrator, Isabel Eslava.

On April 14, 2021, the Department received a complaint report alleging that facility staff threatened resident, R1, with eviction if R1 does not agree with a rate increase.

An initial complaint investigation tele-visit was conducted on April 22, 2021. Staff and resident interviews were conducted. 2 out of 2 staff who were interviewed denied threatening any resident with eviction. 4 out of 4 residents were interviewed and denied being threatened by staff with eviction.

Continued, see LIC 9099-C, page 2 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20210414133152
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: MAYFLOWER CARE HOME
FACILITY NUMBER: 435200608
VISIT DATE: 06/07/2021
NARRATIVE
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On June 4, 2021, former resident (R1) was interviewed and stated that R1 did not have a problem with staff at this facility. R1 was unable to confirm whether staff made threats to R1 or other residents.

The Department has investigated the above allegation. Based on 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 allegation did or did not occur.

Exit interview conducted with licensee/administrator. A copy of this report was provided to facility during visit.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 26-AS-20210414133152
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: MAYFLOWER CARE HOME
FACILITY NUMBER: 435200608
VISIT DATE: 06/07/2021
NARRATIVE
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S1 stated that CCSCC supplements R1's rent payment until Mental Health Housing Authority (MHHA) took over. S1 stated she was not aware that R1 is an SSI (Supplement Security Income) recipient and she did not know why R1 only pays partial rent and CCSCC/MHHA helps with payment.

On August 20, 2020, S1 notified R1 that there will be an increase in R1's rent. S1 stated that R1 agreed to the increase and that the facility began charging R1 the new rate as of December 3, 2020 which is more than 90 days of the notice date. S1 stated there was no notice provided to CCSCC or MHHA of the rate increase.

Facility records were reviewed. Based on R1's admission agreement signed on October 2, 2019, R1 is only responsible to pay the facility $1058.63 per month. CCSCC pays the remaining charges over $1058.63. Investigation revealed that the SSI payment standard for Non-Medical Out-of-Home Care (NMOHC) is $1058.37 for 2019 and $1079.37 in 2021 as indicated in Provider Information Notice (PIN) 18-12-CCLD and 20-26-CCLD, respectively. The facility's admission agreement states on page 3, "If the resident is an SSI/SSP recipient, then basic services shall be provided at the SSI/SSP rate at no additional charge to the resident..."

Records showed that on August 20, 2020, a notice of rate increase was issued by the facility to R1 indicating a $500 increase in R1's financial responsibility effective December 1, 2020. R1 and S1 signed the notice. 2 out of 2 MHHA representatives who were interviewed stated MHHA was not notified by the facility of R1's rate increase. S1 confirmed MHHA is an additional payor for R1.

Records and interviews revealed that the facility refunded R1 $2500 on April 14, 2021 to give back rate increase payments from December 2020 to April 2021. S1 stated she refunded the amount after MHHA informed her that R1 is an SSI recipient.

The Department has conducted an investigation of the above allegations. Based on LPAs’ observations, records and photos reviewed and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Administrator Isabel Eslava. Appeal rights provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20210414133152
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: MAYFLOWER CARE HOME
FACILITY NUMBER: 435200608
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/11/2021
Section Cited
CCR
87464(e)
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87464 BASIC SERVICES. (e) If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made available at the basic rate at no additional charge to the resident. This requirement was not met as evidenced by:
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Licensee to submit written proof of action to CCLD by POC due date. Licensee and LPAs collaborated on POC.
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Based on facility records and interview with Administrator, additional charges were imposed on R1 from 12/2020 to 04/2021 for basic services. The rate increase was over the state's NMOHC rate for 2020 and 2021. This posed a potential risk to the health and personal rights of R1.
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Type B
06/11/2021
Section Cited
CCR
87468.2(a)(12)
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87468.2 ADDITIONAL PERSONAL RIGHTS OF RESIDENTS IN PRIVATELY OPERATED FACILITIES (12)... to receive written notice of any rate increases according to Health and Safety Code sections 1569.655 and 1569.884. This requirement was not met as evidenced by:
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Licensee to submit written proof of action to CCLD by POC due date. Licensee and LPAs collaborated on POC.
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Based on facility records, interview with Administrator and R1's representatives, MHHA was not notified of an increase in R1's rent rate. Administrator confirmed MHHA is an additional payor for R1's rent and is therefore a "responsible person" for R1. This posed a potential risk to the personal rights of R1.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5