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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202891
Report Date: 09/17/2024
Date Signed: 09/17/2024 05:25:59 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
05/23/2024 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20240523112616
FACILITY NAME:RGK HOME CAREFACILITY NUMBER:
435202891
ADMINISTRATOR:LAZARO, MARY GRACE V.FACILITY TYPE:
740
ADDRESS:274 CLEARPARK CIRCLETELEPHONE:
(408) 420-7262
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 6DATE:
09/17/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary LazaroTIME COMPLETED:
02:56 PM
ALLEGATION(S):
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Facility staff did not observe resident was missing from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Administrator (ADM) Mary Lazaro.

On 05/23/2024, the Department received a complaint with the allegation that facility staff did not observe resident was missing from the facility.

On 5/31/2024, LPA conducted an initial investigation visit.

LPA interviewed Administrator, Licensee, 2 staff (S1, S2) and 2 residents (R1, R2). LPA requested resident R1's Individual Program Plan (IPP),Appraisal/Needs and Service Plan, and Physician Report.

Continue on LIC9099-C. Page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
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 4
Control Number 26-AS-20240523112616
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: RGK HOME CARE
FACILITY NUMBER: 435202891
VISIT DATE: 09/17/2024
NARRATIVE
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Facility staff did not observe resident was missing from the facility:

On 5/21/2024, resident R1 was found at the neighborhood of the facility and Police was called. Police officers found R1 was wearing a bracelet which shows the address of the facility. R1 was brought back to the facility by the Police Officers.

On 5/31/2024, LPA interviewed Administrator (ADM). ADM stated on 5/21/2024 morning, resident R1 was in and out the facility main entrance door. ADM stated staff S1 was accompanying with R1, and then S1 took R1 for walking to the near by park. Around 11:30AM, S1 brought R1 back to the facility and R1 took a break at the bedroom. ADM stated S1 started to prepare lunch. ADM stated around 12:30PM, police officers brought R1 back to the facility and the police officers stated R1 was found at the neighborhood. ADM stated he/she and staff did not hear the door alarm sounding.

LPA checked the exit door of R1's bedroom, the alarm sounded when LPA and ADM opened the exit door of R1's bed room..

LPA interviewed resident R1. R1 can tell his/her name and DOB. R1 was unable to say what is the year today. R1 stated he/she likes to live in the facility. R1 cannot remember if he/she eloped from the facility recently.

LPA interviewed resident R2. R2 was able to tell his/her name and DOB. R2 can tell what is the year today. R2 stated he/she knows a resident eloped from the facility recently, but he/she cannot remember what is the date and detail.

LPA interviewed staff S1. S1 stated on 5/21/2024, around 11:00AM he/she took resident R1 to walk to the near by park. S1 stated around 11:30AM, he/she took R1 back to the facility and let R1 stay in the bedroom to take a break. S1 stated he/she then started to prepare the lunch. S1 stated R1 was brought back to the facility by police officers. S1 stated he/she checked R1's body and did not find any wound or bruise. S1 stated staff gave water and lunch to R1. S1 stated R1 is fine after back to normal.


Continue on LIC9099-C. Page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 26-AS-20240523112616
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: RGK HOME CARE
FACILITY NUMBER: 435202891
VISIT DATE: 09/17/2024
NARRATIVE
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LPA interviewed staff S2. S2 stated he/she was off when the incident occurred. S2 stated he/she knew the incident on the next day that R1 eloped from the facility. S2 stated during the incident, staff S1, another staff S3, Administrator and licensee were at the facility. S2 stated police officers brought R1 back to the facility.

LPA interviewed licensee (LCN). LCN stated on 5/21/2024, he/she was working/cleaning at the backyard. LCN stated around 12:30PM the police officers brought R1 back to the facility.

LPA reviewed R1's IPP dated 6/08/2023, page 5, it specifies R1 has a history of wandering/AWOL behavior. LPA reviewed R1's physician report dated 1/24/2024, it specifies R1's cognitive abilities are in a conditional state between normal aging and cognitive impairment, and R1 has history of AWOL.

LPA reviewed R1's Appraisal/Needs and Services Plan dated 5/10/2024, it specifies R1 needs to desist from leaving the facility without notice at all times, day and night. R1 needs to be supervised at all time.

Based on the interviews and records reviewed, the facility did not report R1's elopement incident to CCL office, the facility did not ensure resident R1 received supervision to meet R1's care need.

The Department has investigated the above allegation. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Citations were noted today. Please see LIC9099-D. Appeal right was provided. Exit interview was conducted with ADM. A copy of the report was provide to ADM.

Page 3 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20240523112616
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: RGK HOME CARE
FACILITY NUMBER: 435202891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2024
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements
(a)(1)(D) Any incident which threatens the welfare, safety, or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidenced by:
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Administrator stated to submit plan of correction by the POC due date to ensure the facility to send incident reports to CCL office in timely manner.
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Based on interviews and records reviewed, Administrator did not send R1's elopement incident report to CCL office which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/24/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights (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 stated to submit a plan of correction by the POC due date to provide the training to staff to provide care and supervision to meet residents' needs and to provide the staff training log.
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Based on interview and record review, Licensee did not provide the necessary care and supervision to meet R1's care needs, which resulted in R1's elopement from the facility, which poses/posed 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: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4