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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200791
Report Date: 05/29/2024
Date Signed: 05/29/2024 12:14:38 PM

Substantiated


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
04/30/2024 and conducted by Evaluator Maria Partoza
COMPLAINT CONTROL NUMBER: 26-AS-20240430100728
FACILITY NAME:CONSTANTIN'S CARE HOMEFACILITY NUMBER:
435200791
ADMINISTRATOR:LAPUSTEA, CONSTANTINFACILITY TYPE:
740
ADDRESS:5836 ETTERSBERG DRIVETELEPHONE:
(408) 229-0365
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 6DATE:
05/29/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Constantine Lapustea TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility did not submit incident / death report
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannouced complaint investigation of the above allegation and met with licensee/administrator (ADM) Constantin Lapustea and stated the purpose of the visit.

At the time of the visit LPA observed 4 out of 6 residents are in the facility, 1out of 6 is attending day program, 1 out of 6 is at a skilled nursing facility (SNF), 2 staff (S1 and S2) and LIC/ADM.

LPA continued with the complaint investigation for the following allegation facility did not submit incident / death report when a resident was taken to the hospital and passed away. LIC/ADM stated that he did not know and is not aware that death and other incidents needs to be reported when a resident is taken to the hospital, by family or paramedics. LIC/ADM stated he only reports if it is a fall or accident, or altercations between staff and resident, resident to resident and staff to staff.
page 1 continued to page 2 LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
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 3
Control Number 26-AS-20240430100728
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: CONSTANTIN'S CARE HOME
FACILITY NUMBER: 435200791
VISIT DATE: 05/29/2024
NARRATIVE
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Based on LPAs observations, interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (CCR) Title 22, Division 6, Chapter 8, being cited on the attached LIC 9099D.

LIC/ADM submitted a written statement of understanding for reporting requirement.

An exit interview was conducted with LIC/ADM Constantin Lapustea. A copy of the report and appeal's rights were provided.


page 2
End of Report.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20240430100728
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: CONSTANTIN'S CARE HOME
FACILITY NUMBER: 435200791
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/30/2024
Section Cited
CCR
87211(a)(1)(A)
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87211 Reporting Requirement (a) Each licensee shall furnish to the licensing agency ... reports (1)A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified in (A) Death of any resident.
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LIC/ADM gave a written statement to LPA during today's visit that he/she will comply with Title 22 reporting requirement.
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This requirement was not met as evidenced by:
Based on document review and as stated by LIC/ADM he/she did not submit a death report because the resident passed away in the hospital and not in the facility.
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con't
LIC/ADM stated he/she is not aware that any death should be reported regardless of where it occurred.
Type A
05/30/2024
Section Cited
CCR
87405(d)(2)
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Administrator Qualification (d) administrator shall have the qualifications (2) knowledge of and ability to conform to the applicable laws and regulations.

This requirement was not met as evidenced by:
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LIC/ADM stated that he/whe will submit a statement of understanding for reporting requirements and will conform to the applicable laws and regulations for Title 22
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Based on record review and interview. LIC/ADM did not conform to the applicable laws and regulations. LIC/ADM stated he/she was not aware of the reporting requirements for unusual incidents and death of a resident.
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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: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3