435202934-5-28-2025-26-AS-MPAA-DHJQ2R-20250611114732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202934
Report Date: 05/28/2025
Date Signed: 05/28/2025 04:36:29 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
03/11/2025 and conducted by Evaluator Christine Kabariti

COMPLAINT CONTROL NUMBER: 26-AS-20250311101843

FACILITY NAME:	BONITA SPRINGS CARE HOME		FACILITY NUMBER:	435202934
ADMINISTRATOR:	HAROON, SYEDA LUBNA		FACILITY TYPE:	740
ADDRESS:	853 GERONIMO STREET		TELEPHONE:	(408) 841-0248
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	6	CENSUS: 5	DATE:	05/28/2025
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Syeda Haroon		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Facility staff left resident in soiled diapers for hours
Facility staff did not feed resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the findings of the above allegations. LPA met with Administrator, Syeda Haroon.

On 03/11/2025, the Department received the complaint. On 03/20/2025, the initial complaint investigation was conducted. The following documents were obtained to include resident roster, resident (R1)'s physician's report, preplacement appraisal, progress notes, ADL log, care plan, admission agreement, hospital discharge paperwork, and facility menu.

It was alleged that the facility staff left resident soiled in diapers for hours. It was alleged that when the resident asked the staff to change his/her diaper the staff will take hours to return, but the resident was unable to recall the last time this happened. Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

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-20250311101843

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: BONITA SPRINGS CARE HOME	FACILITY NUMBER: 435202934
	VISIT DATE: 05/28/2025

NARRATIVE

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Based on record review, R1 lived in the facility for only 5 days from 03/05/2025 – 03/09/2025.

3 staff members were interviewed. Based on staff interview, resident (R1) was very demanding and asked to be changed at every hour, even when he/she was dry. It was stated that the facility staff changed R1’s diapers every couple hours, or as needed if resident was soiled. The facility staff logged each time they change, turn and repositioned R1.

1 witness (W1) was interviewed. Based on witness interview, it was stated that R1 asked to be changed and wiped at every hour during the night. W1 states that he/she tried to accommodate to R1's needs and assisted R1 at every request. W1 states there to be one time where W1 was on break eating lunch at the facility's kitchen table where R1 asked to be changed. W1 states that he/she informed R1 that he/she will be back and came back in 15 minutes. W1 denied coming back after an hour.

3 out of 3 staff denied leaving a resident and R1 soiled for a long period of time.

1 resident was interviewed. 4 out of 5 resident interviews were attempted. Based on resident interview, the resident denied being left in soiled diapers for a long time. Resident states that the staff assist him/her whenever he/she needs assistance. Resident stated the staff responds to him/her right away and never had to wait more than 10 minutes for help.

Based on record review of the facility’s activities of daily living (ADL) log, it shows that R1 diaper was changed every 2-3 hours from 03/05/2025 – 03/09/2025.

It was alleged that the facility staff did not feed resident as the resident stated that he/she had not eaten.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20250311101843

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: BONITA SPRINGS CARE HOME	FACILITY NUMBER: 435202934
	VISIT DATE: 05/28/2025

NARRATIVE

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3 staff members were interviewed. Based on staff interview, 3 out of 3 staff states that each resident is provided 3 meals a day and a snack in between, if requested. Staff stated a time where R1 requested food that they did not have at the time but R1 was always offered alternatives. Staff denied R1 ever missing a meal. It was stated that they log each time the resident is provided a meal.

1 resident was interviewed. 4 out of 5 resident interviews were attempted.

Based on resident interview, it was stated that the residents are provided 3 meals a day. Resident denied missing a meal.

During visit on 03/20/2025, LPA observed 2 residents eating breakfast inside their bedrooms. One resident was served pancakes, fruit salad, and coffee that morning. The second resident was observed eating breakfast in his/her room with the assistance of staff. It stated that the remainder of the resident’s wake up earlier, therefore, was fed breakfast earlier.

Based on observation of the facility’s food supplies, the facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods.

The review of records show that R1 was provided 3 meals a day and snacks in between.

The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unfounded, meaning the allegations are false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Syeda Haroon and a copy of the report was provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC9099 (FAS) - (06/04)

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