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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430707097
Report Date: 09/07/2021
Date Signed: 09/10/2021 03:47:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/14/2020 and conducted by Evaluator Yatfai Ng
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20200914095036
FACILITY NAME:PARK AVENUE ADULT RESIDENTIAL FACILITIESFACILITY NUMBER:
430707097
ADMINISTRATOR:EUSTAQUIO,CECILIAFACILITY TYPE:
735
ADDRESS:1992 & 1998 PARK AVENUETELEPHONE:
(408) 241-0605
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:12CENSUS: 11DATE:
09/07/2021
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Cecilia EustaquioTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility has bed bugs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent investigation visit to deliver the finding. LPA met with the Licensee Cecilia Eustaquio.

An initial unannounced tele-investigation was conducted by LPA on 09/24/2020. LPA toured the facility, interviewed 3 residents, and 1 staff. On the same day, LPA interviewed an additional 1 staff over the telephone.

On 09/24/2020, 3 residents were interviewed. 3 out of 3 residents stated that they saw bed bugs in the facility.

On 09/24/2020, 2 staff were interviewed. 2 out of 2 staff admitted there were bed bugs in the facility. A pest control company was contracted to mitigate the bed bugs problem.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
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-20200914095036
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097
VISIT DATE: 09/07/2021
NARRATIVE
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On 10/14/2020, LPA received a letter from a pest control company to confirm it was hired to mitigate the bed bugs problem.

Based on the interviews and file review, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED, which means that the allegation did occur.

A deficiency was cited today per California Code of Regulations, Title 22. See 9099-D for more information.

This report was reviewed with Licensee. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20200914095036
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2021
Section Cited
CCR
80087(a)(1)
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80087 Buildings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
(1) The licensee shall take measures to keep the facility free of flies and other insects.
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Licensee has already submitted pest control’s records to CCL before POC due date. This is corrected prior visit.
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This requirement was not met as evidenced by:
based on interviews: residents and staff saw bed bugs in the facility. This 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: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3