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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200608
Report Date: 03/07/2025
Date Signed: 03/07/2025 03:00:17 PM

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
12/20/2024 and conducted by Evaluator Kenneth Madrigal
COMPLAINT CONTROL NUMBER: 26-AS-20241220135831
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:
03/07/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Isabel Eslava, Administrator (ADM)TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Licensee refusing to allow resident to return to facility after hospitalization.
INVESTIGATION FINDINGS:
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On March 7, 2025, at 8:50 AM, Licensing Program Analysts (LPA), Kenneth Madrigal and Manuel Monter, conducted an unannounced visit to conclude the complaint investigation. LPAs met with Isabel Eslava, Administrator (ADM)/Licensee (LIC).

On December 20, 2024, the California Department of Social Services (Department) received a complaint regarding the above allegation. It has been alleged that the licensee refused R1 to return to the facility on December 20, 2024.

On December 17, 2024, the Deparment received an Incident Report for R1’s hospitalization on December 15, 2024. Incident Report stated R1 was not at baseline and 911 was contacted. R1’s family member informed the facility R1 will be admitted to the hospital for more observations.

Page 1 of 3.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Kenneth Madrigal
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
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-20241220135831
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: MAYFLOWER CARE HOME
FACILITY NUMBER: 435200608
VISIT DATE: 03/07/2025
NARRATIVE
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On December 20, 2024, LPA Tarin interviewed witness (W1) stated that the ADM is using R1’s hospitalization to refuse R1 to return to the facility. W1 stated that R1 was hospitalized on December 15, 2024, R1 is at their baseline, ADM must take R1 back to the facility, and there is no change in level of care.

On December 20, 2024, LPA Tarin interviewed Kaiser Social Service Manager (SSM) stated that R1 has anticipated discharge of December 20, 2024. SSM spoke with the Doctor and R1 will be staying overnight. Also, SSM stated that he/she spoke to ADM who stated he/she feels that R1 requires a higher level of care and R1 exceeds the level of care the facility can provide.

On December 21, 2024, LPM Manzano communicated with ADM. ADM stated that Kaiser nurses were initially not able to provide a medical assessment for R1 at the hospital. ADM stated she wanted more medical information regarding R1’s condition. ADM stated on December 21, 2024, she was informed about R1’s conditions. ADM stated R1 will be discharged to the care home and requested an updated Physician’s Assessment by R1's Primary Care Physician.

On December 26, 2024, LPA Rai conducted an initial complaint investigation. The Department received, obtained, and reviewed the following documents for resident 1 (R1): Physician’s Report and Appraisal Needs & Services Plan (ANS).

LPA Rai interviewed ADM. ADM stated R1 went to the hospital on December 15, 2024, after R1 expressed numbness on the right side of his/her body. ADM stated she assessed R1 on December 17 and 19, 2024, at the hospital. ADM stated that she was waiting to receive an update from the nurses before accepting the resident back to the facility. ADM stated on December 20, 2024, the hospital called to inform R1’s discharge and ADM stated that she wanted to conduct her assessment, but Patient Care Coordinator did not tell ADM R1’s updated diagnosis. ADM stated that she did not refuse R1 and wanted additional assessment regarding his/her conditions. On December 21, 2024, ADM conducted her assessment and nurses informed ADM about R1’s condition. ADM stated that R1 returned to the facility on December 21, 2024.

Page 2 of 3.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Kenneth Madrigal
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20241220135831
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: MAYFLOWER CARE HOME
FACILITY NUMBER: 435200608
VISIT DATE: 03/07/2025
NARRATIVE
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Therefore, based on interviews conducted, on-site observations, and facility records review, the above allegations are false, could not have happened, and/or are without a reasonable basis, therefore the allegations are UNFOUNDED.

During today’s visit, no deficiencies were cited from CCR, Title 22, Division 6. An exit interview was conducted with ADM, Isabel Eslava and a copy of this report was provided to her.

End of Report. Page 3 of 3.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Kenneth Madrigal
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3