430707868-4-3-2024-26-AS-KHOS-D4KGVU-20240422054117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430707868
Report Date: 04/03/2024
Date Signed: 04/03/2024 07:13:52 PM

Unsubstantiated

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
11/17/2021 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20211117083529

FACILITY NAME:	FLORENCE RESIDENTIAL CARE HOME #2		FACILITY NUMBER:	430707868
ADMINISTRATOR:	PERLA DIMALANTA ZEIJNALI		FACILITY TYPE:	735
ADDRESS:	135 NORTH 8TH STREET		TELEPHONE:	(408) 293-0362
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	10	CENSUS: 9	DATE:	04/03/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Winnie Rodriguez		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Lack of supervision resulting in resident injury
Resident care needs are not being met

INVESTIGATION FINDINGS:

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On 4/3/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint inspection. LPA met with staff Winnie Rodriguez and explained the purpose of the visit.

The Department investigated the allegations that lack of supervision resulted in resident injury and resident care needs are not being met and based on staff and resident interviews, there is not a preponderance of evidence to prove or disprove the allegations occurred. The allegations are therefore unsubstantiated.

No deficiencies were cited and exit interview was conducted.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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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