440703228-1-31-2025-26-AS-KHOS-DENQ4B-20250311115005

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 440703228
Report Date: 01/31/2025
Date Signed: 01/31/2025 11:02:53 AM

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
05/14/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240514090217

FACILITY NAME:	HANOVER GUEST HOME		FACILITY NUMBER:	440703228
ADMINISTRATOR:	MARSHA BELLEZA		FACILITY TYPE:	740
ADDRESS:	813 HANOVER STREET		TELEPHONE:	(831) 426-0618
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	15	CENSUS: 12	DATE:	01/31/2025
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator Marsha Belleza		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff did not safeguard resident's personal belongings.
Staff did not provide adequate supervision resulting in resident pushing another resident in care.
Staff handled resident in a rough manner.
Staff did not provide resident's responsible party with resident's documents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Marsha Belleza.

On May 14, 2024, the Department received a complaint alleging Staff did not safeguard resident’s personal belongings. It has been alleged that staff did not safeguard R1’s personal belongings.

On May 21, 2024, LPA Monter interviewed R1’s Conservator. (R1C). R1C stated regarding to safeguarding R1’s belongings has been an ongoing issue since 2016. R1C stated he/she has informed the staff. R1C stated he/she buys R1C a new shirt but then when he/she visits, he/she can't find it. R1C stated this is an ongoing issue.

Page 1 Out of 5

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

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 12

Control Number 26-AS-20240514090217

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: HANOVER GUEST HOME	FACILITY NUMBER: 440703228
	VISIT DATE: 01/31/2025

NARRATIVE

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On May 22, 2024, LPA Monter interviewed ADM. LPA requested to review R1’s personal property form. ADM stated the facility does not have R1’s personal property form and did not fill out a personal property form. ADM stated the majority of R1’s cloths are donations. ADM stated R1’s conservator did not inform her when he/she brought new things to the facility.

On December 4, 2024, LPA Monter interviewed staff S6. S6 stated he/she has not heard anyone complain that R1 has lost or had his/her clothing taken. S1 stated R1 has not gotten cloths from her responsible party. S1 stated the facility has been providing cloths and shoes to R1. S1 stated R1’s responsible party has never mentioned anything about R1 missing cloths.

ON May 21, 2024 and January 31, 2025, LPA interviewed 7 residents, (R1, R2, R3, R4, R6, R8, R9). R1 stated he/she has not had anything lost or stolen. 2 Out of 6 residents (R2 & R6) declined to be interviewed. 5 Out of 7 residents (R1, R3, R4, R8 & R9) stated they have not had any personal property stolen or lost, and facility staff will assist them in finding there property if misplaced.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are 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.

Staff did not provide adequate supervision resulting in resident pushing another resident in care.
On May 14, 2024, the Department received a complaint alleging Staff did not provide adequate supervision resulting in resident pushing another resident in care. It has been alleged that resident R2 pushed R1 in late 2022 or early 2023.

On May 22, 2024, LPA Monter interviewed residents R1-R7. 5 Out of 7 residents interviewed (R1, R3-R5, R7) stated residents don’t push each other and don’t fight with each other. Resident R1 stated he/she has not been pushed by anyone. R2 declined to be interviewed. R6 was unable to answer LPA’s questions due to neurocognitive disorder.

Page 2 Out of 5

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 12

Control Number 26-AS-20240514090217

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: HANOVER GUEST HOME	FACILITY NUMBER: 440703228
	VISIT DATE: 01/31/2025

NARRATIVE

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LPA Monter interviewed staff S1-S5 and ADM. 5 Out of 5 staff interviewed stated they have not seen resident R2 push R1. All staff interviewed stated resident R1 has been seen pushing R2. ADM stated state resident R2 does not push R1. ADM stated R1 is the aggressor and pushes R2.

On December 4, 2024, LPA Monter interviewed staff S6. S6 stated resident R1 has been seen pushing R2. S6 stated R2 does not push R1.

On January 31, 2025, LPA Monter interviewed Staff S2, S3, S7. 3 Out of 3 staff interviewed stated resident R1 and R2's room door is in the dinning area, which has a direct line of sight for staff in the dinning area and kitchen. 3 Out of 3 staff stated redirect R1 and R2 to do activities and if there is a any potential commotion, staff will intervene.

LPA interviewed ADM. ADM stated the facility staff aware aware of Resident R1's behaviors. ADM stated R1's bedroom is in the line of sight of staff in the dinning room and kitchen. ADM stated staff will keep Resident R1 and R2 occupied. ADM stated she has instructed staff to keep an eye on them and intervene at any sign of potential conflict between R1 and R2.

Based on a facility record review, there are no incident reports regarding the alleged push in late 2022 or early 2023. There are also no incident reports noting any hospitalization's for R1 in late 2022 or early 2023.

Based on investigation, records reviewed, and interviews conducted, 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.

Staff did not provide resident's responsible party with resident's documents.
On May 14, 2024, the Department received a complaint alleging Staff did not provide resident’s responsible party with resident’s documents. It has been alleged a residents conservator requested a copy of the resident’s previous payment history.

Page 3 Out of 5

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 12

Control Number 26-AS-20240514090217

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: HANOVER GUEST HOME	FACILITY NUMBER: 440703228
	VISIT DATE: 01/31/2025

NARRATIVE

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On May 21, 2024, LPA Monter interviewed R1’s Conservator, R1C. R1C stated he/she requested a copy of R1’s history of payments in the beginning of the year, 2024. R1C stated he/she has not yet received the documentation.

On May 22 and December 12, 2024, LPA Monter interviewed ADM. ADM stated she has sent over the history of payments to R1C. ADM stated she did not send this information via certified mail. ADM stated she did send the documents but did not record the exact date she sent them.

On December 4, 2024, LPA Monter interviewed staff S6, stated the facility has provided R1’s responsible party with a copy of receipts. S6 stated the facility made copies and sent them via mail to R1’s responsible party via physical mail. S1 stated the facility has asked R1’s responsible party for their actual mailing address, so they can send the receipts thru verified mail, to ensures he/she gets them. S1 stated R1’s responsible party only provide them with the PO Box.

Based on investigation, records reviewed, and interviews conducted, 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.

Staff handled resident in a rough manner.
On May 14, 2024, the Department received a complaint alleging Staff handled resident in a rough manner. It has been alleged near the end of April 2024, staff S6 grabbed R1’s arms and pulled him/her.

On May 21, 2024, LPA Monter interviewed Witness W1. W1 stated R1 had an appointment and needed to get inside the car. W1 stated HM grabbed R1’s arms, pulled him/her to the car. W1 stated staff S3 saw this. W1 stated R1 did not sustain an injury from the pull.

On May 22, 2024, LPA Monter interviewed residents R1-R7. 5 Out of 7 residents (R1, R3-R5, R7) interviewed stated the staff are not rough when assisting them and do not pull residents arm in a rough manner. R1 stated the staff are not rough with him/her and staff doesn’t pull on his/her arms. R2 declined to be interviewed. R6 was unable to answer LPA’s questions due to neurocognitive disorder.
Page 4 Out of 5

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 12

Control Number 26-AS-20240514090217

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: HANOVER GUEST HOME	FACILITY NUMBER: 440703228
	VISIT DATE: 01/31/2025

NARRATIVE

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LPA interviewed staff S1-S5 and ADM. 5 Out of 5 staff interviewed stated staff are not rough with residents. 5 Out of 5 staff interviewed they have not seen other staff or the house manager handling the residents in a rough manner. ADM stated she has not seen staff or HM handle the residents in a rough manner.

On December 4, 2024, LPA Monter interviewed staff S6. S6 stated he/she has never seen staff handle residents in a rough manner. S6 stated he/she has never handled residents in a rough manner or yanked/pulled residents in a rough manner.

Based on investigation, records reviewed, and interviews conducted, 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.

Page 5 Out of 5.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 12

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
05/14/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240514090217

FACILITY NAME:	HANOVER GUEST HOME		FACILITY NUMBER:	440703228
ADMINISTRATOR:	MARSHA BELLEZA		FACILITY TYPE:	740
ADDRESS:	813 HANOVER STREET		TELEPHONE:	(831) 426-0618
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	15	CENSUS: 12	DATE:	01/31/2025
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator Marsha Belleza		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff did not allow resident to change rooms.
Staff does not ensure facility is free of bed bugs.
Staff increased residents rent without notice

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Marsha Belleza.

On May 14, 2024, the Department received a complaint alleging Staff did not allow resident to change rooms. It has been alleged Staff did not allow resident to change rooms.

On May 21, 2024, LPA Manuel Monter interviewed Resident R1’s Conservator. R1C stated he/she requested to have R1 moved to another bedroom in 2015.

Page 1 Out of 4

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

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

LIC9099 (FAS) - (06/04)

Page: 6 of 12

Control Number 26-AS-20240514090217

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: HANOVER GUEST HOME	FACILITY NUMBER: 440703228
	VISIT DATE: 01/31/2025

NARRATIVE

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On May 22 and December 12, 2024 LPA Monter interviewed ADM. ADM stated she has been informed by R1’s conservator of moving R1 in another room sometime in March/April 2024. ADM stated the other shared bedrooms residents are also not a good fit for R1 and they can’t move the residents without the resident’s permission. ADM stated R1’s current, roommate, R2 cannot be moved either. ADM stated R2’s responsible party prefers R2 stay in the same bedroom to keep things consist for him/her. ADM stated she has no objection to R1 switching rooms with another resident who stays in a shared bedroom. ADM stated she must respect the residents personal rights and the residents themselves and the families must agree to this change.

On December 4, 2024, LPA Monter interviewed staff S6. S6 stated the facility has tried to move R1/R2 to other bedrooms. S6 stated they haven’t had the opportunity, because other families don’t want to either share the bedroom, or have R1/R2 move in. S6 stated the facility has made the attempt, but the resident’s family don’t want to make the change.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, 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.

Staff does not ensure facility is free of bed bugs.
On May 14, 2024, the Department received a complaint alleging Staff does not ensure facility is free of bed bugs. It has been alleged that resident R1’s bed has bed bugs.

On May 22, 2024, LPA Manuel Monter interviewed staff S1-S5 and ADM. 5 Out of 5 staff interviewed stated they have not seen bed bugs at the facility. ADM stated the facility has checked R1’s bed and there are no signs of bedbugs.

LPA Monter interviewed residents R1-R7. 5 Out of 7 residents (R1, R3-R5, R7) interviewed stated they have not seen bed bugs at the facility. R2 declined to be interviewed. R6 was unable to answer LPA’s questions due to neurocognitive disorder.

Page 2 Out of 4

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

Page: 7 of 12

Control Number 26-AS-20240514090217

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: HANOVER GUEST HOME	FACILITY NUMBER: 440703228
	VISIT DATE: 01/31/2025

NARRATIVE

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On May 22, 2024, LPA Monter randomly inspected 6 beds for bed bugs, including R1 bed. LPA inspected the beds by asking facility ADM to remove the blankets and bed sheets. LPA then checked the edges of the mattress for any sign of bed bugs. LPA also inspected the edges of the bed frame. LPA found no signs of bed bugs, droppings or blood in the beds inspected.

On December 4, 2024, LPA Monter interviewed staff S6. S6 stated the facility does not have bed bugs and it’s a false allegation.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, 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.

Staff increased residents rent without notice
On May 14, 2024, the Department received a complaint alleging Staff increased residents rent without notice. It has been alleged that R1’s rent has been raised without notice.

On May 13 and 27, 2024, the Department interviewed R1’s Conservator (R1C). R1C stated he/she was informed via text message, on January 31st 2024, that rent was going up from $2250-$4000. R1C notified facility ADM that he/she could not afford such an increase. R1C stated during their back and forth text between him/her and the ADM, the ADM stated, “if you keep paying on time, I will not charge any additional fee and you don’t owe me anything as long as you move R1 out as soon as possible.” R1C stated he/she replied, “Great! Thank you.”

On December 4, 2024, LPA Monter interviewed staff S6. S6 stated the facility did raise R1’s rent and they did notify R1’s responsible party. S6 stated, the issue is R1’s responsible party is still paying the same amount of money. S6 stated they have sent him/her 3 notices but no response and R1’s responsible Party is still sends the same amount of money.

Page 3 Out of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

Page: 8 of 12

Control Number 26-AS-20240514090217

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: HANOVER GUEST HOME	FACILITY NUMBER: 440703228
	VISIT DATE: 01/31/2025

NARRATIVE

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On December 12, 2024, LPA Monter interviewed ADM. ADM stated she did raise the rent for R1. ADM stated she gave R1’s responsible party a letter with the changes in rent. ADM stated this letter/email was given to R1’s responsible party in the first few months of 2024. ADM stated the changes would have gone into effective May 2024. ADM stated she sent the letter to R1’s PO box.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, 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.

Page 4 Out of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

Page: 9 of 12

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
05/14/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240514090217

FACILITY NAME:	HANOVER GUEST HOME		FACILITY NUMBER:	440703228
ADMINISTRATOR:	MARSHA BELLEZA		FACILITY TYPE:	740
ADDRESS:	813 HANOVER STREET		TELEPHONE:	(831) 426-0618
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	15	CENSUS: 12	DATE:	01/31/2025
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator Marsha Belleza		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

1
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8
9

Staff blocks/locks facility passageways

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Marsha Belleza.

On May 14, 2024, the Department received a complaint alleging staff blocks/locks facility passageways.

On May 22, 2024, LPA Manuel Monter conducted an initial complaint investigation visit. During the visit, LPA Monter observed latch locks in two of the facility exits. The Latch locks were observed in the exit next to the living room/dining area. Another latch was observed in the exit in front of bedroom #9. LPA also observed a chain with a Master lock in the front gate of the facility.

Page 1 Out of 2.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

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

LIC9099 (FAS) - (06/04)

Page: 10 of 12

Control Number 26-AS-20240514090217

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: HANOVER GUEST HOME	FACILITY NUMBER: 440703228
	VISIT DATE: 01/31/2025

NARRATIVE

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LPA Monter interviewed staff S1-S5 and ADM. S1 and S2 they have not seen the facility exits locked when they work. Staff S3-S5 stated the facility locks the doors and gate because R2 has a wandering behavior. ADM stated a staff member put the locks because R2 has a wandering behavior at night. ADM acknowledged that this is a form of restraint.

Based on interviews and observation of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

The Department is issuing an immediate civil penalty of $250 a repeat violation for the following deficiencies:
87307 Personal Accommodations and Services (d)(6), which was previously cited on August 27, 2024.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator Marsha Belleza and a copy of the report was provided. Appeal Rights was provided.

Page 2 Out of 2. END OF REPORT

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

Page: 11 of 12

Control Number 26-AS-20240514090217

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: HANOVER GUEST HOME	FACILITY NUMBER: 440703228
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/03/2025 Section Cited CCR 87307(d)(6)	1 2 3 4 5 6 7	87307 Personal Accommodations and Services (d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the Plan of Correction by POC date, Febuary 3, 2025.
	8 9 10 11 12 13 14	Based on interviews and observation, the facility was locking the exit next to the dinning area, room 9, and front entrance of the facility. ADM stated R2 has an exit seeking behavior. ADM acknowledged this was a form of restraint. This poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

Page: 12 of 12