435200608-6-17-2025-26-AS-KHOS-DJ5JMY-20250630071107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200608
Report Date: 03/09/2025
Date Signed: 06/17/2025 02:11:08 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2024 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20241007153228

FACILITY NAME:	MAYFLOWER CARE HOME		FACILITY NUMBER:	435200608
ADMINISTRATOR:	ESLAVA, ISABEL M.		FACILITY TYPE:	740
ADDRESS:	668 APACHE COURT		TELEPHONE:	(408) 972-1999
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 6	DATE:	03/09/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Isabel Eslava		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility issued an unlawful eviction notice due to change of resident condition.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 03/09/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Isabel Eslava, who was briefly interviewed at this time.
Current census was (6) residents.
The purpose of this visit was to deliver the findings of this investigation to this facility, and it's designated Administrator, at this time.
Based on interviews and a review of the forms and documents that were retrieved during this investigation, it was learned that resident, R1, initially moved into this facility back in June 2024. It was learned that shortly after admission this facility, and it's representative, served R1 with an eviction notice. This eviction notice was issued due to the alleged need for a higher level of care with concerns for maintaining skin integrity and requiring a 2-person assist at all times. This initial eviction notice was given to R1 and R1's responsible family and friends on 07/12/2024 merely a few weeks after admission.
Based on a review of the forms and documents, it was learned that a second eviction notice was issued on

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2025

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-20241007153228

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: MAYFLOWER CARE HOME	FACILITY NUMBER: 435200608
	VISIT DATE: 03/09/2025

NARRATIVE

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09/02/2024 which cited the following issues and reasons for this eviction notice:

Thin skin and easily bruising with concerns for maintaining skin integrity
Need to be on the toilet requiring assistance to get to the restroom
Assistance with transferring requiring use of a Hoyer lift
Issues with staying up late due to being on the toilet for long periods of time
Requiring 2 staff members for assistance with Activities of Daily Living (ADLs)

It was learned that a third eviction notice was also issued on 10/29/2024 to R1 and R1's responsible family and friends citing the following issues and reasons for this eviction notice:

R1's inability to independently transfer
Pressure injuries and issues with maintaining skin integrity

Based on a review of the facility forms and documents submitted into CCL, it was learned that an Appraisal/Needs and Services Plan (LIC 625) was completed for R1 by this facility designated Administrator on 06/24/2024 which was at the time of R1's admission into this facility. It was learned that the issue of needing assistance with transferring was duly noted and deemed that a Hoyer lift would be employed in order to provide adequate care and supervision to R1.
It was also noted on this LIC 625 that R1 had a history of bruising easily and sustaining skin tears was also a constant risk. It was learned that this facility designated Administrator planned to involve the licensed medical professional and the Home Health agency to assist in this matter and noted it as such on this form.
Based on a review of the facility forms and documents for R1, it was learned that from a completed Physician's Report (LIC 602) dated on 04/12/2024 stated that R1 was diagnosed with dementia and deemed to be Bedridden at that time. It was learned that this LIC 602 was completed two months prior to R1 being admitted to this facility. It was learned that the facility designated Administrator was made aware of this information and was provided a copy of this LIC 602.
Based on interviews and a review of the facility forms and documents, it was learned that shortly after being admitted to this facility R1 was then served with an eviction notice to vacate the premises within 30 days since this facility, and its staff, were no longer able to provided the appropriate level of care and supervision to R1 at that time.
Based on interviews and a review of the facility forms and documents, this facility designated Administrator

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20241007153228

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: MAYFLOWER CARE HOME	FACILITY NUMBER: 435200608
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/10/2025 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-Admission Appraisal and	1 2 3 4 5 6 7	The facility designated Administrator stated that she will undergo training, for no less than one hour in duration, on the subject matter of facility residents rights and proper eviction procedures and how to properly maintain them at all times. A statement of correction, along with copies of the updated training, will
	8 9 10 11 12 13 14	providing the other basic services specified below, either directly or through outside resources. This facility was found to be deficient as evidenced by the issuance of (3) eviction notices to a resident, and their responsible family and friends, citing issues with a higher level of care and care needs that were already made aware to this facility upon admission which poses an immediate threat to the Health, Safety, and Personal Rights to residents in care.	8 9 10 11 12 13 14	will be completed and submitted into CCL by the due date. Proof of completed training will involve the topic of training, name of the vendorized trainer, and list of attendee(s).
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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: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20241007153228

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: MAYFLOWER CARE HOME	FACILITY NUMBER: 435200608
	VISIT DATE: 03/09/2025

NARRATIVE

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was well aware of the health conditions and issues that afflicted R1 upon admission to this facility. An LIC 625 was completed along with updated information from the LIC 602 that was completed two months prior to the admission of R1 into this facility.
It was learned that this facility already had a resident under the care of hospice who was deemed to also be bedridden at that time. This facility was already deploying the use of a Hoyer lift in helping to transfer this hospice resident in/out of bed, in/out of their wheelchair, and assistance with toileting as well.
It was learned that this eviction notice was served to R1 and R1's responsible family and friends once R1 was admitted and presented additional issues and workload for this facility to take on at that time. This facility already was approved to be able to accept and retain up to (2) residents under the care of hospice at any given time. In addition, this facility was approved and fire cleared to be able to accept and retain up to (1) bedridden resident at any given time. This facility already had the approved programs needed in order to provide the adequate care and supervision to a resident diagnosed with dementia, resident on hospice, and a resident who needed assistance with transferring and toileting needs due to being bedridden.

As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2025

LIC9099 (FAS) - (06/04)

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