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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202713
Report Date: 04/16/2026
Date Signed: 04/16/2026 02:04:16 PM

Substantiated


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
10/22/2025 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20251022113846
FACILITY NAME:RACHELLE'S HOME IFACILITY NUMBER:
445202713
ADMINISTRATOR:RECINTO, RACHELLEFACILITY TYPE:
740
ADDRESS:99 AIRPORT BLVDTELEPHONE:
(831) 319-4190
CITY:FREEDOMSTATE: CAZIP CODE:
95019
CAPACITY:12CENSUS: 5DATE:
04/16/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tyrone VegaTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility currently has only one operational toilet available for an approved 14 capacity due to overflowing septic.
Facility did not report physical plant or maintenance issue at the facility to licensing which threatens resident's welfare, safety or health.
INVESTIGATION FINDINGS:
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On 10/22/2025, the Department received a complaint with the above allegations. On 10/29/2025, LPA Marrufo conducted an initial complaint investigation visit. On 02/12/2026, LPA Marrufo conducted an additional complaint investigation visit.

Allegation: Facility currently has only one operational toilet available for an approved 14 capacity due to overflowing septic.

When the department received the complaint, it was alleged that the facility had a damaged septic system.

See LIC9099-C pages for more information. Page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
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 5
Control Number 26-AS-20251022113846
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: RACHELLE'S HOME I
FACILITY NUMBER: 445202713
VISIT DATE: 04/16/2026
NARRATIVE
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Allegation: Facility did not report physical plant or maintenance issue at the facility to licensing which threatens resident's welfare, safety or health.

When the department received the complaint, it was alleged that the facility had not reported that the facility had a damaged septic system for two months.

On 10/28/2025, the department received an Unusual Incident/Injury Report (IR) from the facility. The IR was dated 10/28/2025 and stated that date of occurrence of the incident was 10/28/2025. The IR states, “On October 28, 2025, at approximately 9:00 AM, plumbing inspection and repair work began in the main bathroom of Rachelle’s Home I. The inspection was scheduled and confirmed by the facility’s maintenance. Due to the scope of the bathroom repair, residents were temporarily relocated to the other areas of the home to ensure safety and privacy during the work.”

Based on records review, interviews, and observations there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegations are substantiated.

See LIC9099-D for deficiencies cited as per the California Code of Regulations, Title 22.

This report was reviewed with Assistant Administrator Tyrone Vega and a copy of this report and appeal rights were provided.

Page 3 of 3.

END REPORT
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20251022113846
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: RACHELLE'S HOME I
FACILITY NUMBER: 445202713
VISIT DATE: 04/16/2026
NARRATIVE
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During visit on 10/29/2025, LPA Marrufo toured the facility and observed two out of two resident bathrooms. One bathroom, on the left side of the facility, had a handwritten sign posted on the door that said, “Out of Order.” LPA toured the inside of the bathroom.

During visit on 10/29/2025, LPA Marrufo interviewed staff S1-S3 and Licensee Rachelle Recinto. S1 stated that the left-side bathroom had been intermittently out of order for about a month. S2 stated that the left-side bathroom had become clogged shortly after he/she began working at the facility, but S2 did not specify a time. S3 stated the left-side bathroom had become clogged about a month prior and would go back and forth between being operable and inoperable. Licensee Rachelle Recinto stated the left-side bathroom had become clogged on 10/20/2025. Licensee stated the a repair appointment had been attempted but there was no availability. Licensee stated a facility maintenance staff had rented a “snake” and fixed the plumbing, but there was still a plumbing appointment that was scheduled.

On 02/17/2026, LPA Marrufo obtained a copy of an invoice from a plumbing contractor. The invoice is dated 10/15/2025. The invoice identifies the address of the job as identical to the address of the facility. The invoice project description states, “Upon video inspection from 2-way cleanout [redacted] found old cast iron main sewer line towards building compromised by severe rust scale build up along interior walls of sewer pipe. [Redacted] will restore main sewer line by descaling, sanding and flushing all heavy rust scale out of sewer line. This will also include pulling toilet in 1 of 2 back to back bathrooms to descale sewer branch line to lateral sewer.” The invoice states Witness W1 was a technician on the project.

On 04/09/2026, LPA Marrufo conducted a telephone interview with W1. During interview, W1 stated that he/she had been at the facility doing maintenance work and the facility staff told him/her that the bathroom on the left side of the facility had not been working for months. W1 stated he/she found that the left-side bathroom was not working. W1 stated he/she pulled out five gallon-sized buckets worth of wipes, which he/she stated should not be flushed down the toilet. W1 stated that the sewage line from the left bathroom probably had a blockage that had not been removed for multiple months. W1 stated that although rust build ups occur with aging cast iron pipes, blockages make the rust build ups worse. W1 stated the blockage could have been avoided by having the sewage pipes services when they became blocked.

Page 2 of 3.
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20251022113846
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: RACHELLE'S HOME I
FACILITY NUMBER: 445202713
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2026
Section Cited
CCR
87303(e)(6)
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87303(e)(6) Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in
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Licensee shall submit a Plan of Correction by POC date of 04/17/2026 stating how the Licensee shall ensure that toilets, handwashing, and bathing facilities will be maintained in operating condition, including contracting a professional plumbing service when needed.
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facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement was not met as evidenced by: Licensee did not ensure that 1 out of 2 facility toilets had a sewage line that was maintained in operating condition, which posed an immediate health risk to residents in care.
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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: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20251022113846
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: RACHELLE'S HOME I
FACILITY NUMBER: 445202713
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/23/2026
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for
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Licensee agrees to conduct in-service training with staff on ensuring that reports are made to the licensing agency for any incident which threatens the welfare, safety, or health of any resident, including reporting when a toilet or sewage line is no longer in operating condition. Once training is complete, the Licensee shall submit copies of training records, including names of staff trained, training dates, training topics, and names and qualifications of trainers by Plan of Correction due date of 04/23/2026.
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the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: Licensee did not ensure that a report was furnished to the licensing agency regarding inoperability of one out of two facility toilets and its attached sewage line, which posed a potential health and safety risk to residents in care.
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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: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5