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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202643
Report Date: 10/25/2024
Date Signed: 10/25/2024 04:46:57 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
03/14/2023 and conducted by Evaluator Chihhsien Chang
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230314081243
FACILITY NAME:AMY'S RESIDENTIAL CARE, INC.FACILITY NUMBER:
435202643
ADMINISTRATOR:SINGH, JAGTARFACILITY TYPE:
740
ADDRESS:671 N WHITE RDTELEPHONE:
(408) 898-8784
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 5DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Amarjeet MannTIME COMPLETED:
01:29 PM
ALLEGATION(S):
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Staff are not feeding resident.
INVESTIGATION FINDINGS:
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This report is being amended from Substantiated to Unfounded.

On 10/25/2024, Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the amended investigation findings and met with Administrator (ADM) Amarjeet Mann. This complaint allegation is being amended after new information has been received by the Department,

On 3/14/2023, the Department received a complaint with the above allegation.

On 9/18/2024, the Department delivered the investigation finding for complaint number
26-AS-20230314081243.

Continue on LIC9099-C. page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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 2
Control Number 26-AS-20230314081243
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: AMY'S RESIDENTIAL CARE, INC.
FACILITY NUMBER: 435202643
VISIT DATE: 10/25/2024
NARRATIVE
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Staff are not feeding resident:
The allegation is that resident R1 has difficulty in swallowing food and needs longer time to be fed for meals.

On 3/17/2023, LPA interviewed 2 staff(S1, S2). 2 Out 2 staff stated the facility always has 2 staff during the meal time to feed residents. 2 Out 2 staff denied the facility staff did not feed resident R1.

During the visit, LPA observed resident R1 was thin. LPA interviewed R1. R1 is nonverbal. R1 replied the questions by nodding or shaking his/her head for yes or no. R1 nodded his/her head when was asked if the staff fed him/her with 3 meals per day. R1 nodded his/her head when was asked if he/she felt hungry.

LPA interviewed ADM. ADM denied the facility staff did not feed R1. ADM stated R1 has difficulty in swallowing food because R1 has deteriorated swallowing mechanism. ADM stated he/she will have a dedicated staff to take care of R1 to spend more time to feed R1.

On 10/17/2024, LPA interviewed House Manger (HM). HM stated staff spent around 20-30 minutes to feed other residents, and spent around one and half hours to feed R1.

LPA interviewed staff S1. S1 stated he/she spent at least one hour to feed R1. S1 stated he/she did not force R1 to be fed if R1 closed his/her mouth. S1 stated R1 never requested more food, and sometimes R1 refused to eat.

Based on the review of R1's physician report dated 3/17/2023, R1 is unable to feed self, and R1 does not have special diet. Based on review of R1's Appraisal/Needs and Service Plan dated 3/1/2023, R1 needs 1 person assists feeding. R1 is on pureed diet with thicken liquids, and soft food as tolerated.

The Department has investigated the above allegation. Based on the investigation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview was conducted with ADM. A copy of this report was provided to ADM. Page 2 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2