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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430707097
Report Date: 10/26/2024
Date Signed: 10/26/2024 05:02:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20221007161203
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: 12DATE:
10/26/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:CeciliaTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility has bed bugs
INVESTIGATION FINDINGS:
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On 10/26/2024, LPA johnson arrived unannounced to investigate and deliver findings for the allegations listed above.

During the course of the investigation LPA reviewed pasted interviewed staff, residents and the Admininstrator and confirmed today that the facility had bedbugs.

The facility provided the invoice from past pest control and current. Based on a information provided through interviews, the allegation that the facility has bedbugs was Substantiated. This agency has investigated the allegation notice and has found the allegation to be Substantiated meaning that there was a preponderance of evidence to prove the allegation was true as reported.

The following deficiency was cited per Title 22 Provision 6 of the CA Code of Regulations. An exit interview was conduct.

A copy of this report along with appeal rights was provided.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2024
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 4
Control Number 26-AS-20221007161203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
80087(a)(1)
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(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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The facility has ongoing treatment from the exterminator for pest control including monthly visits to ensure that bedbugs and pest are not present in the facility.
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This requirement was not met as evidenced by observation The facility provided records of past and current visits from the exterminator. The facility had services for the bedbugs and currently there have been no signs for bedbugs.
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LPA obtained copies of the pest control treatment plan
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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: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20221007161203

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: 12DATE:
10/26/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:CeciliaTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
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9
Staff do not allow residents' time to eat
Staff not providing proper hygiene for residents
INVESTIGATION FINDINGS:
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Allegation: Staff do not allow residents' time to eat.

Based on interviews with residents the facility allows 50 minutes to eat. Some residents confirmed that they would not finish all their meals and others stated that they had enough time to finish their meals with time to spare. These conditions for eating with time requirements were a result of the Covid mandate for congregated living and each facility was using Covid protocols for dining.

During the current investigation all residents interviewed confirmed that they have time to eat and there is no issue with not finishing the meals.
Continued
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20221007161203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097
VISIT DATE: 10/26/2024
NARRATIVE
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Allegation: Staff not providing proper hygiene for residents.
Based on interviews and observation the facility at the time (2022) did not have hygiene products in the bathrooms. The Administrator confirmed today that the facility gives toilet paper to each resident and will provide additional hygiene items if needed or requested by the residents. Some residents provide for themselves with hygiene needs. The residents do not require assistance with bathing or showering. Some residents take showers three time a week and some take a shower once a week.

The allegations are unsubstantiated.


 
An unsubstantiated finding means although the allegation 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.

Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4