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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202834
Report Date: 05/31/2024
Date Signed: 05/31/2024 11:26:57 AM

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
03/01/2024 and conducted by Evaluator Simranjit Rai
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20240301084844
FACILITY NAME:ANDREA'S ELDERLY CARE FACILITY #2FACILITY NUMBER:
435202834
ADMINISTRATOR:ROQUE, PERCIVALFACILITY TYPE:
740
ADDRESS:1525 FRANKLIN ST.TELEPHONE:
(408) 605-2033
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:6CENSUS: 6DATE:
05/31/2024
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Licensee, Felina Roque TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff member yells at resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Licensee, Felina Roque and stated the purpose of today’s visit. During visit, LPA Rai observed three staff members and 6 residents in the resident rooms.

On 3/1/2024, the Department received a complaint with the above allegations. On 3/6/2024, the Department conducted an initial investigation at the facility. It was alleged the facility staff were yelling at resident (R1) when R1 requests for help.

Continuation on LIC 9099-C, Page 1 of 2.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
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-20240301084844
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: ANDREA'S ELDERLY CARE FACILITY #2
FACILITY NUMBER: 435202834
VISIT DATE: 05/31/2024
NARRATIVE
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Page 2 of 2.

On 3/6/2024, LPA Rai conducted interviews with 2 staff (S1-S2). S1 and S2 assist resident with care and supervision, and they have stated they do not yell or shout at the residents at the facility. They stated R1 is hard of hearing and staff will speak loudly to R1. 2 out of 2 staff stated they did not see or hear other facility staff yell at the residents.

On 3/6/2024, LPA Rai conducted interviews with 5 residents. 3 Out of 5 residents were not able to verbally communicate with LPA Rai. LPA Rai was able to interview 2 residents (R1-R2). R1 stated S1 yells at him/her but “its not his fault, it’s China zodiac sign’s fault that R1 is mad”. R1 stated staff are not yelling at him/her because R1 cannot hear and needs staff to raise their voices. R2 stated the staff do not yell but the residents are yelling at the facility staff. R2 stated the staff “treat me nice” and R2 “feels safe and comfortable”. R2 stated the staff are not angry or agitated.

Based on R1’s Needs and Services Plan dated 2/29/2024, R1 is dependent in all activities of daily living and one of the objectives for staff to reassure R1 that caregivers are there to help and assist R1 and staff are always there to listen and assist R1 if there is a problem. Based on R1’s Physician’s Report dated 6/19/2023, R1 does not have auditory impairment.

On 3/19/2024, the Department interviewed R1’s primary care physician (PCP). PCP stated R1 is hard of hearing and that may be the reason why the staff will raise their voice. PCP does not believe the staff have malicious intent.

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

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Licensee, Felina Roque and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2