430700136-3-21-2025-26-AS-MPAA-DJWMFQ-20250725093443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430700136
Report Date: 03/21/2025
Date Signed: 03/21/2025 02:14:55 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
11/01/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20231101151155

FACILITY NAME:	CHANNING HOUSE		FACILITY NUMBER:	430700136
ADMINISTRATOR:	GONZALEZ-MENDOZ, YADIRA S.		FACILITY TYPE:	741
ADDRESS:	850 WEBSTER STREET		TELEPHONE:	(650) 327-0950
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94301
CAPACITY:	264	CENSUS: 229	DATE:	03/21/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Beth Shirley		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are yelling at residents and not according residents with dignity.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Beth Shirley, Assistant Administrator. On 11/01/2023, the department received a complaint with the above allegation. LPA Marrufo conducted an initial complaint investigation visit on 11/09/2023.

LPA Marrufo obtained a copy of the Unusual Incident/Injury Report (IR) that the facility submitted to the department on 10/30/2023. The IR states that on 10/30/2023 resident R1 reported to the facility Administrator (ADM) that staff S1 was disrespectful to R1 on two different occasions.

The first occasion involved an incident in which S1 was assisting another resident who is known to have aggressive behaviors in the common area. R1 stated that S1 used a raised voice to tell R1 to go back to his/her room.
See LIC9099-C pages for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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 3

Control Number 26-AS-20231101151155

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: CHANNING HOUSE	FACILITY NUMBER: 430700136
	VISIT DATE: 03/21/2025

NARRATIVE

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The second occasion involved S1 raising his/her voice at R1 when S1 found R1 on another floor of the building. R1 stated S1 used a raise voice towards R1 to ask R1 what R1 was doing and to tell R1 that R1 is not supposed to be in that part of the building alone.

LPA Marrufo obtained a copy of resident R2’s Appraisal/Needs and Services Plan (ANS). R2’s ANS states, “The resident has episodes of being verbally aggressive towards other residents,” and “Resident had an incident of physical aggression with another resident, the resident moved [his/her] walker and hit another resident on [his/her] right leg.”

LPA Marrufo obtained a copy of written statements made by staff as part of an internal investigation by the facility. The internal investigation had interviews of six staff. One of the six interviewed staff, S2, stated to have observed the incident in which R2 was having aggressive behaviors and S1 was attempting to supervise and redirect R2. S2 stated that while R2 was having aggressive behaviors, R1 was sitting in the common area. R2 stated that S1 was attempting to tell R1 to go to his/her room and that the area was not safe. S2 stated that S1 did not raise his/her voice at R1 but used a firm, but not disrespectful tone. S2 stated that S1 was encouraging R1 to go to his/her room. S2 stated that R1 continued to walk towards R2 and walked around R2.

On 11/09/2023, LPA Marrufo interviewed R1. R1 stated that R1 had an incident with a staff, but did not want to name the staff. R1 stated that a resident used his/her walker to block R1 and a staff. R1 stated the resident uses the walker “almost as a weapon.” R1 stated to have asked the resident to let him/her out and R1 was able to walk past the resident, but the resident continued to block the staff. R1 stated the staff did not say anything to R1, but R1 did not like that the staff told R1’s child that he/she was protecting R1 from the resident with the walker.

On 11/09/2023, LPA visited R2, who had a private care giver at the facility. LPA Marrufo attempted to interview R2. However, R2 appeared confused, and LPA Marrufo did not continue with the interview. LPA Marrufo interviewed R2’s private care giver, who stated that R2 does block people with R2’s walker.

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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20231101151155

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: CHANNING HOUSE	FACILITY NUMBER: 430700136
	VISIT DATE: 03/21/2025

NARRATIVE

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On 03/21/2025, LPA Marrufo conducted a telephone interview with S1. S1 stated to recall R1 and recall the incident involving R2 having aggressive behaviors while R1 was in the common area. S1 stated that R2 has been both verbally and physically aggressive towards others. S1 stated that R2 was being verbally aggressive and S1 feared that R2 may become physically aggressive. S1 stated that S1 told R1 that R2 was not in a good mood and the situation was not good. S1 stated that S1 may have suggested to R1 to go back to his/her room, but did not use an angry or disrespectful tone and did not yell at R1. S1 stated to have not acted in a way that did not give R1 dignity.

S1 stated to have never yelled at R1 or spoken to R1 in a disrespectful or angry tone while R1 was in an elevator on another floor of the building.

LPA Marrufo obtained copies of R1’s training logs, which include “Dementia Bill of Rights” completed on 03/29/2023, “Mandated Reporting,” completed on 04/24, 2023, “Interpersonal Communication” completed on 7/11/2023, and “Res. Behaviors, Narcotic Count, Breaks, Trays, Res. Appts, TEFs, Meal Waivers, Announcements” on 10/26/2023.

Based on information from interviews conducted with staff and residents, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22.

This report was reviewed with Beth Shirley, Assistant Administrator and a copy of this report was provided.

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END REPORT

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC9099 (FAS) - (06/04)

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