430707097-9-29-2021-26-AS-SYIP-C7JN9Y-20211006101640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430707097
Report Date: 09/24/2021
Date Signed: 09/29/2021 09:59:24 AM

Unsubstantiated

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
07/22/2020 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200722153130

FACILITY NAME:	PARK AVENUE ADULT RESIDENTIAL FACILITIES		FACILITY NUMBER:	430707097
ADMINISTRATOR:	EUSTAQUIO,CECILIA		FACILITY TYPE:	735
ADDRESS:	1992 & 1998 PARK AVENUE		TELEPHONE:	(408) 241-0605
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY:	12	CENSUS: 12	DATE:	09/24/2021
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Diosdado Zabal		TIME COMPLETED:	05:55 PM

ALLEGATION(S):

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Uncleared staff working at facility.
Resident's needs are not being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent investigation visit to deliver the findings. LPA met with the Caregiver Diosdado Zabal.

An initial unannounced tele-investigation was conducted by LPA on 07/30/2020. LPA toured the facility, interviewed 1 staff. On 08/05/2020, LPA interviewed 2 staff and 6 residents.

Between 07/30/2020 and 08/05/2020, 3 staff were interviewed. 3 out of 3 staff denied there were uncleared staff working at the facility. All staff stated they only have 4 staff including the licensee working at the facility. 3 out of 3 staff stated there was water readily available in the facility. All 3 staff denied the resident’s needs were not being met.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20200722153130

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: 09/24/2021

NARRATIVE

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Between 08/05/2020 and 09/07/2021, 7 residents were interviewed. 7 out of 7 residents denied seeing other staff working at the facility except these 4 staff who are cleared and associated. All residents were able to name all the staff working which matched the staff roster. 7 out of 7 residents stated there was water available in the facility. All 7 residents stated there was water for residents. 2 residents were asked if they saw the licensee go on vacation. Both residents denied seeing that. Licensee also denied going on vacation or being absent that required coverage last year.

On 09/07/2021, LPA made an unannounced visit to the facility. LPA did not see any uncleared staff working at the facility. The 2 staff present were cleared and associated with the facility. During visit, LPA observed residents who were having meals in the dining room and had water present to consume.

Based on record review, all staff as mentioned by the residents are cleared and associated.

Based on interviews, observation, and record review, the department has determined that the allegations were UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

This report was reviewed with Caregiver. A copy of this report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

LIC9099 (FAS) - (06/04)

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