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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600162
Report Date: 07/01/2025
Date Signed: 07/01/2025 10:04:48 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250502114652
FACILITY NAME:ISMAELA'S HOME CARE, INC.FACILITY NUMBER:
415600162
ADMINISTRATOR:CHARITO RAFAELFACILITY TYPE:
740
ADDRESS:468 HAZEL AVENUETELEPHONE:
(650) 615-9937
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 5DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver, Paul MedinaTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff member threatened resident in care
Staff member yelled at resident in care
INVESTIGATION FINDINGS:
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On July 1, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint investigation findings. Upon entry, LPA met with caregiver, Paul Medina and explained the purpose of today's visit. The Licensee, Florinda Gunito arrived shortly thereafter and LPA explained the purpose of the visit.

Regarding to the allegation of- staff member threatened resident in care, the reporting party stated that after licensing's visit and told the licensee that resident's are not to be spoken to with a raised voice, nor retaliated against, a staff member told a resident, "if you are not happy here, we can just close this place down".

As part of the investigation, LPA interviewed the licensee, and the residents.

The Licensee stated she was not aware of any staff members threatened the residents but they have decided to close the facility and they have provided the 60-day facility closure notice to the residents, the responsible party, the case managers, the Ombudsman and CCL. The licensee also stated that they are working with the resident's case manager on discharging the residents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
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 5
Control Number 14-AS-20250502114652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ISMAELA'S HOME CARE, INC.
FACILITY NUMBER: 415600162
VISIT DATE: 07/01/2025
NARRATIVE
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LPA interviewed resident #1(R1) and resident #2 (R2) who stated that after a visit from the LPA and the Ombudsman, they were told by staff in a threatened manner, "Bye Bye". In addition, both of these residents related this information to a State Official.

After the investigation, this allegation is deemed to be substantiated.

Regarding to the allegation of- staff member yelled at resident in care- the reporting party stated that when resident #1 (R1) asked the staff about the medication, the staff telling R1 "I am busy" and yelled at R1.

As part of the investigation, LPA interviewed staff #1 (S1), and R1 and another resident.

According to S1, they never yelled at R1 and other residents. S1 stated that R1 was recently hospitalized and returned to the facility with a lot of new medication and changes with the current ones. R1 was persistent and asked about the changes of all the medications before S1 had a chance to review them with the hospital nurse so S1 told R1 to wait but never yelled at R1.
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LPA interviewed R1 who stated that he/she was afraid of S1 and S1 yelled at R1 and other residents.

LPA interviewed R2 who stated that S1 got angry one day during dinner and yelled at R1.

Residents also reported to a State Official that S1 got angry and yelled at them.

After the investigation, this allegation is deemed to be substantiated.

Based on interviews, record reviews, and observations during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.
Report was discussed with the licensee; a copy is provided with Appeal Rights provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 14-AS-20250502114652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ISMAELA'S HOME CARE, INC.
FACILITY NUMBER: 415600162
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2025
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature,...
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The administrator/licensee will develop a plan to ensure all residents are being treated with dignity and respect. The plan shall include staff training. The administrator/licensee will provide a copy of the plan to CCL by 7/2/2025.
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This requirement is not met as evidenced by based on observation and interviews.. R1 and R2 reported that they were being threatened and yelled at by facility staff which poses an immediate 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: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250502114652

FACILITY NAME:ISMAELA'S HOME CARE, INC.FACILITY NUMBER:
415600162
ADMINISTRATOR:CHARITO RAFAELFACILITY TYPE:
740
ADDRESS:468 HAZEL AVENUETELEPHONE:
(650) 615-9937
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 6DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver, Paul MedinaTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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9
Staff member did not provide assistance to resident in care as needed.
INVESTIGATION FINDINGS:
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On July 1, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint investigation findings. Upon entry, LPA met with caregiver, Paul Medina and explained the purpose of today's visit. The Licensee, Florinda Gunito arrived shortly thereafter and LPA explained the purpose of the visit.

Regarding to the allegation of - staff member did not provide assistance to resident in care as needed, the reporting party stated that an anonymous resident was administered new medication, and they asked staff member (S1) to provide assistance and to explain the new medications to them, S1 refused to help.

According to S1, there was only one resident (R1) who was recently hospitalized and returned to the facility with a lot of medication changes and R1 was adamant about wanting to know the changes before they had a change to review it with the hospital nurse. S1 stated that after they verified the medication orders with the hospital nurse, they reviewed it with R1.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20250502114652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ISMAELA'S HOME CARE, INC.
FACILITY NUMBER: 415600162
VISIT DATE: 07/01/2025
NARRATIVE
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LPA interviewed R1 who stated that S1 initially got angry and yelled at S1 when S1 asked about the medication changes (this was addressed on LIC 9099) but later S1 explained it to R1 after speaking to the hospital nurse. R1 also stated that S1 is very knowledgeable with R1's medication.

Based on these observations, and interviews the above allegation is deemed to be UNSUBSTANTIATED.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated.

The report is reviewed and discussed with the Licensee.

A copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5