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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294284
Report Date: 08/18/2025
Date Signed: 08/18/2025 01:10:26 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
05/23/2025 and conducted by Evaluator Kiran Jain
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20250523163931
FACILITY NAME:ST. MARY'S RESIDENTIAL CARE HOME IIFACILITY NUMBER:
435294284
ADMINISTRATOR:ARIMAS, MARILUZ & MERLINOFACILITY TYPE:
740
ADDRESS:1265 SOCORRO AVENUETELEPHONE:
(408) 390-4931
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:6CENSUS: 6DATE:
08/18/2025
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Karen MarcelaTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Facility staff did not provide resident with care, supervision, and services
Facility did not allow home health nurse visit to a resident while in care
INVESTIGATION FINDINGS:
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On August 18, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to deliver and discuss the findings of a complaint allegation and investigation. Upon arrival, LPA met with caregiver (S1), Karen Marcela and disclosed the purpose of the visit.

On 05/23/2025, the Department received a complaint with allegations that “Facility staff did not provide resident with care, supervision, and services” and “Facility did not allow home health nurse visit to a resident while in care”.

On 08/05/2025, during the facility visit, LPA observed R1 sitting in a wheelchair in the living room watching TV, with S1 seated next to R1 and attending to R1.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
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 4
Control Number 26-AS-20250523163931
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: ST. MARY'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435294284
VISIT DATE: 08/18/2025
NARRATIVE
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On 05/28/2025 and 08/05/2025, LPA interviewed three (3) staff members (ADM, S1, and S2) and R1’s POA.

R1’s POA stated that facility staff attended to R1’s needs very well, consistently monitored R1, and provided daily updates on R1’s condition. Medications were always administered on time. POA stated that they visit R1 at the facility 6 to 7 days a week. The ADM and staff provided the best possible care, and there was no neglect. R1 ate well, and a food assistant was available. R1’s POA expressed being very satisfied with the care provided, stating that R1 was receiving the best care possible for R1’s condition. R1 was not on total care and did not have ulcers, falls, or bruises.

R1’s POA stated that the RP was not helpful, refused to come on 05/20/2025 to evaluate R1, did not want to know R1’s symptoms, and offered the ER as the only option, and instructed staff to take R1 to the hospital. R1’s POA further stated that they decided not to allow RP to visit the facility on 05/21/2025 to see R1, as they have already changed the home health agency and expressed being very satisfied with the new agency, noting improved communication.

ADM stated that on 05/20/2025, staff showered R1, and R1 ate all meals, did not vomit, and did not have a fever. R1 appeared tired, confused, and was not walking around. Staff updated R1’s POA when the POA visited the facility that evening. The POA called RP and asked RP to visit the facility to evaluate R1; however, RP refused to come and instructed the POA to take R1 to the hospital. The POA and ADM decided not to call 911 since R1 was sleeping and instructed staff to observe R1 throughout the night and call 911 if there was an emergency.

The next day, the POA and ADM decided to have R1 transported to the hospital via ambulance for evaluation. While at the hospital, the POA requested a change of home health agency. When RP called ADM on 05/21/2025, ADM informed RP not to come to the facility as R1 was in the hospital and the POA had already requested a new home health agency.

ADM further stated that R1 was not on total care. R1 walked with a walker, received PT at the facility for exercises, could feed themself, and could get up from bed. R1 had not experienced any falls and never had bruises or injuries. Occasionally, R1 experienced episodes of hallucinations, and some medications caused R1 to feel tired.

Continued on LIC9099-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20250523163931
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: ST. MARY'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435294284
VISIT DATE: 08/18/2025
NARRATIVE
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S1 stated that they were not working on 05/20/2025; however, the next day, they observed R1 to be weak, remaining in bed and unable to get up. ADM and R1’s POA came to check on R1 and decided to have R1 taken to the hospital for evaluation. S1 stated that they observed changes in all residents and communicated with ADM or called 911 if needed. S1 further stated that it was R1’s POA who wanted to change the home health agency, as RP had refused to come to evaluate R1.

S2 stated that on 05/20/2025, R1 was very sleepy, and RP called ADM requesting that 911 be called to take R1 to the hospital. ADM asked S2 to check on R1, and S2 informed ADM that R1 was sleeping. The next day, R1’s POA came to the facility and decided to have R1 taken to the hospital, as R1 was unable to stand. S2 stated that they had no idea why ADM did not allow RP to come to the facility.

On 05/28/2025, LPA received and reviewed R1’s LIC602 Physician’s Report, dated 03/24/2025, which stated that R1’s diagnosis was Parkinson’s Dementia, with mental condition noted as confused, and that R1 was able to communicate needs and feed themself.

On 05/28/2025, LPA received and reviewed R1’s LIC625 Appraisal/Needs and Services Plan, dated 03/01/2024 and signed by R1’s POA on 08/11/2024, which stated that R1 required assistance with transferring in and out of bed and was able to walk using a walker.

On 05/28/2025, LPA received and reviewed R1’s LIC9172 Functional Capability Assessment, dated 11/17/2022, which stated that R1 was confused at times, required assistance with transferring, could feed themself completely or with help from another person, walked with support, and used a walker and/or wheelchair.

On 05/28/2025, LPA received and reviewed R1’s progress notes for 05/20/2025, which stated that R1 was more confused than usual, was weak, unable to get up from bed, and that R1’s POA was called regarding R1’s condition.

On 05/28/2025, LPA received and reviewed R1’s hospital discharge report, dated 05/25/2025, which stated that R1 had a urinary tract infection (UTI).

Continued on LIC9099-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20250523163931
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: ST. MARY'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435294284
VISIT DATE: 08/18/2025
NARRATIVE
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Based on observations, interviews conducted, and records reviewed, the facility staff provided R1 with care, supervision, and services. R1’s POA visited the facility frequently, received regular updates, and expressed high satisfaction with the care provided. There was no evidence of neglect or failure to meet R1’s care needs. The refusal for RP to come on 05/21/2025 occurred when R1 was already in the hospital, and the decision to change home health agency originated from R1’s POA, not from a facility policy to deny access while R1 was in care. The timing and circumstances did not demonstrate that the facility wrongfully denied necessary medical services. The Department has determined that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation(s) are UNSUBSTANTIATED.

No deficiencies were cited under the California Code of Regulations, Title 22.

An exit interview was conducted with the Caregiver. A copy of this report was discussed and provided to the Caregiver, Karen Marcela, whose signature on this form confirms receipt of this report.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4