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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202749
Report Date: 08/31/2023
Date Signed: 08/31/2023 04:55:53 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
11/16/2021 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20211116092305
FACILITY NAME:CARING HANDS RESIDENTIAL LIVING IIFACILITY NUMBER:
435202749
ADMINISTRATOR:OKORO, SYLVESTER OFACILITY TYPE:
740
ADDRESS:1324 BAGELY WAYTELEPHONE:
(614) 747-3443
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:6CENSUS: 4DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator OkoroTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff failed to provide adequate supervision, resulting in resident wandering away from the facility.
INVESTIGATION FINDINGS:
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On 11/16/2021 the department received a complaint alleging the facility staff failed to provide adequate supervision, resulting in resident wandering away from the facility.

On 11/11/2021, At approximately 1:39pm San Jose Police Officers received a dispatch call regarding a missing person at 1324 Bagely way San Jose Ca 95122. Resident R1’s care giver, staff member S1, had reported that R1 had dementia and was last seen at 12:00pm. Before arriving at the care home, San Jose police officers received an additional call stating the missing person was found in front of the callers home. Police officers found R1 0.8 miles away from the facility unattended.

San Jose Police officers interviewed S1. S1 stated he/she was taking a shower around 12:00pm. S1 stated when he/she got out of the shower, he/she noticed R1 was no longer in the facility.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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
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
11/16/2021 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20211116092305

FACILITY NAME:CARING HANDS RESIDENTIAL LIVING IIFACILITY NUMBER:
435202749
ADMINISTRATOR:OKORO, SYLVESTER OFACILITY TYPE:
740
ADDRESS:1324 BAGELY WAYTELEPHONE:
(614) 747-3443
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:6CENSUS: 4DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator OkoroTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
Resident(s) not allowed to use the phone while in care.
Staff speaks to resident(s) in an inappropriate manner.
INVESTIGATION FINDINGS:
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On 11/16/2021 the department received a complaint alleging staff speak inappropriately to residents.

On 08/31/2023 LPA Monter interview 4 out of 4 residents. All residents interviewed stated the staff do not speak inappropriately to them. Residents R1 and R2 stated S1 did not speak to them in an inappropriate way.

LPA interviewed ADM and staff (S2). ADM stated no resident complained or mentioned inappropriate speaking from staff. S2 denied the allegations and stated he/she is welcoming and engaging with the residents, nothing disrespectful or degrading.


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Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20211116092305
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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749
VISIT DATE: 08/31/2023
NARRATIVE
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The Department has completed the investigation of the above allegations. Based on interviews conducted and record review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Resident(s) not allowed to use the phone while in care.

On 11/16/2021 the department received a complaint alleging residents are not allowed to use the facility phone.

On 08/31/2023 LPA Monter interview 4 out of 4 residents. All residents interviewed stated they have access to the facility phone and can use it.

LPA interviewed ADM and S2. ADM stated all residents have access to the facility phone and can use it. S2 stated the residents have access to the phone with no restrictions.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

This report was reviewed via phone call with Administrator Okoro and staff member Burchelle signed on ADM's behalf. A copy of the report was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20211116092305
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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749
VISIT DATE: 08/31/2023
NARRATIVE
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Based on review of R1’s Physician Report dated 9//09/2020, R1 has a dementia diagnosis and R1 is not able to leave the facility unassisted. R1 also has wandering behavior.

A review of R1's preplacement appraisal, states that R1 has a diagnosis of dementia.

Based on interviews and documents reviewed, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed via phone call with Administrator Okoro and staff member Burchelle signed on ADM's behalf. A copy of the report was provided. Appeal Rights was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20211116092305
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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by:
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Administrator submit a written plan on understanding regulations by POC date. Administrator agreed and understood.
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On 11/11/2021, R1, who is demented left the facility unassisted and was found by law enforcement unattended which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5