435202912-9-28-2024-26-AS-RMAO-D9VUCK-20241009152803

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202912
Report Date: 09/28/2024
Date Signed: 09/28/2024 01:31:25 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
08/24/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230824110123

FACILITY NAME:	MARY'S HOUSE #2		FACILITY NUMBER:	435202912
ADMINISTRATOR:	MENDOZA, ROSANA		FACILITY TYPE:	740
ADDRESS:	324 BURNING TREE DR		TELEPHONE:	(408) 439-1703
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95119
CAPACITY:	6	CENSUS: 4	DATE:	09/28/2024
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Administrator, Armando Guba		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Resident did not have a complete annual assesment
Facility neglected residents dental care needs

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, Armando Guba and stated the purpose of today’s visit.

On 8/24/2023, the Department received a complaint with the above allegations. On 9/1/2023, the Department conducted an initial investigation at the facility.

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: 09/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024

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-20230824110123

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: MARY'S HOUSE #2	FACILITY NUMBER: 435202912
	VISIT DATE: 09/28/2024

NARRATIVE

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Page 2 of 2.

Resident did not have a complete annual assessment.
It was alleged the facility did not complete an annual assessment for R1.

Based on review of R1’s Physician's Report dated 12/20/2021, R1 does not have neurocognitive disorder wherein R1 would require an annual assessment. Based on interview of facility staff, R1 did not have a change of condition which would require facility staff to assess the resident. Based on facility records, R1's file did contain Appraisal/Needs and Services Plan dated 1/20/2022.

Facility neglected residents dental care needs.
It was alleged R1 was not taken to a dental appointment.

On 9/1/2023, the Department interviewed 4 staff (S1-S4). Four of the four staff stated R1’s family is responsible to call the doctor and dental appointments. S3 and S4 stated R1’s responsible party is setting up dental appointment and transporting R1 to the dental appointments.

On 9/1/2023, the Department interviewed 2 residents (R1-R2). Two out of two residents stated the facility staff provides dental care needs and their responsible parties arrange for dental appointments. R1 and R2 stated they do not have any concerns about the staff assisting them with dental care needs.

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, Armando Guba and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
08/24/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230824110123

FACILITY NAME:	MARY'S HOUSE #2		FACILITY NUMBER:	435202912
ADMINISTRATOR:	MENDOZA, ROSANA		FACILITY TYPE:	740
ADDRESS:	324 BURNING TREE DR		TELEPHONE:	(408) 439-1703
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95119
CAPACITY:	6	CENSUS: 4	DATE:	09/28/2024
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Administrator, Armando Guba		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

1
2
3
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5
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7
8
9

Facility neglected residents grooming and hygiene needs.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20230824110123

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: MARY'S HOUSE #2	FACILITY NUMBER: 435202912
	VISIT DATE: 09/28/2024

NARRATIVE

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Page 2 of 2.

Facility neglected residents grooming and hygiene needs.
It was alleged the facility staff did not provide R1 grooming and hygiene needs.

On 9/1/2023, the Department interviewed 4 staff (S1-S4). S2 stated three out of four residents are seen by the podiatrist that comes to the facility. R1’s responsible party is responsible to find a podiatrist and R1 has routine appointment to see podiatrist set up by R1’s responsible party. S3 stated the residents are bathed three times a week.

On 9/1/2023, the Department interviewed 2 residents (R1-R2). Two out of two residents stated the facility provides grooming and hygiene needs and they do not have any concerns about the staff.

Based on review of R1’s Functional Capability Assessment dated 5/2/2022 and Appraisal/Needs and Services Plan dated 1/20/2022, R1 needs help with bathing and toileting and staff will encourage R1 to call for assistance for toileting needs.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Armando Guba and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4