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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600883
Report Date: 12/20/2023
Date Signed: 03/22/2024 11:03:11 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
08/21/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230821165002
FACILITY NAME:ROSEL'S HOMEFACILITY NUMBER:
415600883
ADMINISTRATOR:JOHN RUZZEL SKAGGSFACILITY TYPE:
735
ADDRESS:2033 OREGON AVENUETELEPHONE:
(650) 387-9488
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:4CENSUS: 4DATE:
12/20/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Co Licensee/Administrator - Romar RaquinilTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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- Staff hit resident causing injury
- Staff caused bruising to resident while in care due to physical abuse
INVESTIGATION FINDINGS:
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 *** THIS IS AN AMENDED REPORT WITH AMENDED LIC9099D PAGES***

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint visit in order to deliver findings regarding the allegations stated above. LPA met with licensee Selene Cruz and explained the purpose of today's visit. LPA and licensee met off site due to the facility having newly COVID positive residents.

During the course of the investigation the Department conducted interviews and reviewed medical records regarding the resident in care. It was found that R1 did sustain injuries related to being struck by S1 on 08/13/2023. On that date S2 witnessed S1 striking R1 a minimum of 3 times in the stomach resulting in bruising during a behavioral incident R1 was having on that day. On 08/21/2023 the bruising was discovered by day program staff when R1 showed staff the bruising. The day progarm then reported this to the facility on the same day. Local police department was notified and made contact with the facility on 08/22/2023.

Continued on next page
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
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-20230821165002
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: ROSEL'S HOME
FACILITY NUMBER: 415600883
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2023
Section Cited
CCR
80072(a)(2)
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80072(a)(2) Personal Rights - (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This regulation has not been met as evidenced by:
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The licensee shall provide a written plan on how they will meet this regulation at all times and preventing a violation of this regulation in the future. The licensee shall provide the Department with a written plan of corrections by the date specified here within.
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During the investigaton, it was found that the resident was punched by R1 in the stomach which resulted in bruising of the resident during a behavioral episode on 08/13/2023. These discoveries display that the resident was not accorded their safe and healhful accomodations by staff.
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Type A
12/21/2023
Section Cited
CCR
80064(a)(3)
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80064(a)(3) Administrator Qualifications and Duties - (a)The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation.

This regulation has not been met as evidenced by:
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The licensee shall provide a written plan on how they will meet this regulation at all times and preventing a violation of this regulation in the future. The licensee shall provide the Department with a written plan of corrections by the date specified here within.
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During the investigation, it was found that appropriate reporting practices were not displayed by the administrator as they failed to accurately report the incident and did not meet the resident's medical needs after bruising was discovered on 08/14/2023 on the body of R1.
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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: Ley Arquisola
LICENSING EVALUATOR NAME: Vivien Helbling
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 14-AS-20230821165002
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: ROSEL'S HOME
FACILITY NUMBER: 415600883
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2023
Section Cited
CCR
80075(a)
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80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.

This regulation has not been met as evidenced by:
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The licensee shall provide a written plan on how they will meet this regulation at all times and preventing a violation of this regulation in the future. The licensee shall provide the Department with a written plan of corrections by the date specified here within.
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During the investigation, it was found that R1 sustained bruises due to physical abuse by S1 during an incident that occurred on 08/13/2023. Also on 08/13/23 R1 fell at least twice during the behavioral incident. On 08/14/2023 the bruises were observed by staff on the body of R1. R1 did not receive medical attention until 08/23/2023. The resident did not receive medical services after the discovery of injuries sustained.
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Type A
12/21/2023
Section Cited
CCR
80065(a)
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80065 Personnel Requirements(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This regulation has not been met as evidenced by:
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The licensee shall provide a written plan on how they will meet this regulation at all times and preventing a violation of this regulation in the future. Licensee to provide the training necessary to staff. The licensee shall provide the Department with a written plan of corrections by the date specified here within.
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During the investigation, it was found that S1 and S2 performed a restraining technique that they are not trained to do. Due to them not having the appropriate training S1 and S2 did not have the competency to use any restraint techniques.
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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: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20230821165002
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: ROSEL'S HOME
FACILITY NUMBER: 415600883
VISIT DATE: 12/20/2023
NARRATIVE
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Page 2 - LIC9099

Additionally during the investigation by the Department it was also discovered that the facility failed to seek timely medical care for R1 for the incident that occurred on 08/13/2023 where the resident fell in the facility and also was punched by S1 after having a behavioral outburst. On 08/14/2023 the facility did a body check of R1 and found bruises on the stomach of R1. R1 did not receive medical attention until 08/23/2023 which indicates that R1 did not receive the medical attention they needed in a timely manner.

It was also discovered that S1 and S2 performed a restraint on R1 without being properly trained on Crisis Prevention Institute (CPI) techniques. CPI cards were reviewed to confirm that the staff persons did not have the training certifications to do so.

Based on the investigation conducted by the Department, interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.

The deficiencies for the substantiated allegations are cited in accordance with California Code of Regulations, Title 22, Division 6 and is noted on attached LIC9099D. The Licensee was informed that additional civil penalties may be assessed. Report is reviewed with Co Licensee/Administrator - Romar Raquinil and a copy is provided with appeal rights. A copy of the civil penalty will be provided

Report is reviewed with Co Licensee/Administrator - Romar Raquinil.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20230821165002
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: ROSEL'S HOME
FACILITY NUMBER: 415600883
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2023
Section Cited
CCR
80063(a)
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80063(a) Accountability - (a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.

This regulation has not been met as evidenced by:
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The licensee shall provide a written plan on how they will meet this regulation at all times to provide more supervision of the licensed facility and preventing a violation of this regulation in the future. The licensee shall provide the Department with a written plan of corrections by the date specified here within.
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During the investigation, it was found that there were discrepancies regarding reporting to the licensee. The licensee did not monitor or supervise the administrator and as a result a resident was punched in the stomach and restrained.
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Type A
12/21/2023
Section Cited
HSC
1796.44(a)
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1796.44 Training Requirements - (a) A licensee shall ensure that prior to providing home care services, an affiliated home care aide shall complete the training requirements specified in this section.

This regulation has not been met as evidenced by:
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The licensee shall provide a written plan on how they will provide all the training needed to the current and incoming staff to meet the needs of the residents outlined in this health and safety code section and preventing a violation of this regulation in the future.The licensee shall provide the Department with a written plan of corrections by the date specified here within.
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During the investigation, it was found that not all staff are trained in areas specific to the client population of the facility and additional training is needed to meet all the requirements outlined in this health and safety code.
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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: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5