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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202834
Report Date: 12/21/2024
Date Signed: 12/21/2024 12:00:39 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
07/29/2024 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20240729100816
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: 4DATE:
12/21/2024
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Back-Up Administrator/Lead Staff, Lerma Espiritu TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff handles resident in a rough manner.
Staff speaks inappropriately to resident.
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 the Administrator and stated the purpose of today’s visit.

On 7/29/2024, the Department received a complaint with the above allegations. On 8/8/2024, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 3.

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

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
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-20240729100816
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: 12/21/2024
NARRATIVE
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Page 2 of 3.

Staff handles resident in a rough manner.
It was alleged facility staff are rough when they clean resident (R1).

On 8/8/2024, the Department interviewed 4 staff (S1-S4). Four out of four staff stated the staff are not rough when they clean R1. Three out of the four staff interviewed provide direct care to R1. Three out of three staff stated they are not rough when they clean resident (R1). All three staff stated they are gentle with R1. All three staff stated they follow R1’s directions when they provide care, so the staff are not rough.

On 8/8/2024, the Department interviewed 5 residents (R1-R5). Three out of five residents did not answer LPA’s questions or refused to be interviewed. Two out of two residents stated they receive care and assistance from the facility staff and the staff are not rough with them.

Based on review of staff training in 2024, staff have received the following training including Sexual Harassment & Abusive Conduct Prevention Training.

Staff speaks inappropriately to resident.
It was alleged facility staff are verbally abusive to resident (R1) but details about the verbal abuse incident were not provided.

On 8/8/2024, the Department interviewed 4 staff (S1-S4). Four out of four staff stated they staff do not use inappropriate words to the resident. All four staff stated R1 is hard of hearing and staff will speak loudly to R1. Four out of four staff stated they do not see or hear other facility staff speaking inappropriately to resident.

On 8/8/2024, the Department interviewed 5 residents (R1-R5). Three out of five residents did not answer LPA’s questions or refused to be interviewed. Two out of two residents stated they receive care and assistance from the facility staff and the staff are not rough with them.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20240729100816
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: 12/21/2024
NARRATIVE
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Page 3 of 3.

Based on review of staff training in 2024, staff have received the following training including Sexual Harassment & Abusive Conduct Prevention Training.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, 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.

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

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3