435294024-2-4-2026-26-AS-CKAI-DTCS2E-20260421132923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294024
Report Date: 02/04/2026
Date Signed: 02/04/2026 01:03:12 PM

Unsubstantiated

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
11/03/2025 and conducted by Evaluator Marcela Yanez

COMPLAINT CONTROL NUMBER: 26-AS-20251103095327

FACILITY NAME:	PACIFIC GARDENS		FACILITY NUMBER:	435294024
ADMINISTRATOR:	ZAHODNE, MATTHEW		FACILITY TYPE:	740
ADDRESS:	2384 PACIFIC DR		TELEPHONE:	(408) 985-5252
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	104	CENSUS: 67	DATE:	02/04/2026
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Matthew Zahodne		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff caused an injury to a resident while in care
Staff did not timely address a resident's change in medical condition while in care

INVESTIGATION FINDINGS:

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On 02/04/26 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint investigation visit to deliver findings. LPA announced the purpose of the visit and met with Matthew Zahodne.

During visit LPA interviewed 2 staff including ADM and obtained pertinent Resident documents.

On 11/03/25 the department received a complaint with the above allegations.

On 11/03/25 LPA Yanez conducted an initial complaint investigation visit and obtained pertinent documents.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20251103095327

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: PACIFIC GARDENS	FACILITY NUMBER: 435294024
	VISIT DATE: 02/04/2026

NARRATIVE

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During the investigation the department interviewed 1 witness, 3 residents and 5 staff.

Resident R1 moved into the Memory Care Unit on 08/03/23 due to wandering behavior. R1 behavior log showed aggressive behavior dated 09/09/24, 11/27/24, 07/21/25, 08/25/25, 08/26/25, 09/09/25, 09/23/25 10/24/25, 10/25/25 10/26/25, 10/28/25 and 10/31/25. R1s Appraisal Needs and Services Plan was updated 10/22/25 and states R1s family to be notified and to try to redirect resident. R1s behavior became a danger to him or herself and facility informed R1s family during an incident and R1s family would arrive to assist in calming R1 down.

On 10/31/25 the department received a special incident report regarding R1 having behavior and altercation with staff that occurred on 10/26/25, the incident report stated that R1 had behavior and attempted to kick and punch staff and suffered a finger fracture.

On 10/31/25 after the incident R1 went to the hospital via ambulance where R1 became aggressive with hospital staff. R1 did not return to facility after incident.

Witness (W1) stated that R1s behavior was due to the facility not forcing R1 to take his/her medication. W1 was reminded that facility staff cannot force Resident to take medication, and it is noted in their file when they refuse medication. W1 stated that the facility should use more force in R1 taking his/her medication. R1s responsible party was called every time resident had behavior and would come to the facility to try to calm R1 down. W1 stated that R1 would calm down once he/she saw them.

5 out of 5 staff stated that R1s aggression and behavior had escalated from the time resident moved into the Memory Care unit and had aggressive episodes and would punch caregivers. 5 out of 5 staff stated that on 10/31/25 R1 had behavior and attempted to pull S1s fingers back and while pulling S1s fingers back was flailing his/her arm. R1 was also observed to have kicked and punched 2 other staff that were present. 3 out of 3 staff stated that R1 had accidentally hit him/herself and R1s nose began to bleed. S3 stated he/she called 911 and shortly after paramedics arrived with local law enforcement and took R1 to the hospital.

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20251103095327

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: PACIFIC GARDENS	FACILITY NUMBER: 435294024
	VISIT DATE: 02/04/2026

NARRATIVE

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Amended report

On 10/31/2025, at approximately 0951 hours, R1 was brought to the Emergency Department (ED) from the facility by ambulance after becoming agitated and physically engaging with S1 while receiving his/her morning medication. R1 was diagnosed with a “minimally displaced nasal bone fracture, medical documentation determined that the fracture could have resulted from an unwitnessed fall, or from an altercation, because R1 noted that he/she was elbowed in the nose by S1. On 10/30/2025, R1 suffered an unwitnessed fall, staff called EMT’s, but since R1 was at baseline, R1s POA preferred R1 not to be transferred to the ED.

S2 has had training in handling critical incidents and is called when staff need assistance with resident who are having behavior in de-escalating techniques including redirecting agitated residents. S2 uses techniques like using a preferred activity to diffuse resident behavior. S2 stated that when a resident attempts to physically engage with staff the staff disengage and move residents nearby for safety and attempt to de-escalate the situation. S2 stated that after any incident the family is immediately notified as well as the Residents primary care physician. S2 stated that R1s behavior is triggered when R1 has nothing to do. S2 would give R1 daily tasks like pouring water into cups when handing out medication to residents to engage R1.

R2 stated that he/she had seen R1s recent behavior had become more aggressive. R2 stated that R1 on one occasion was seen pulling on S1s fingers and S1 was not able to pull away and R1 was out of control and had uncontrollable rage. R2 stated that he/she felt that staff did not overstep their boundaries with R1. R2 stated that R1 could possibly hurt him/herself due to the flailing arms and trying to hit staff.

Based on investigation, interviews conducted, and records reviewed, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

This report was reviewed with Matthew Zahodne, and a copy of the report was provided.

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

LIC9099 (FAS) - (06/04)

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