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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430707868
Report Date: 03/17/2025
Date Signed: 03/17/2025 05:42:10 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
06/07/2022 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 26-AS-20220607120058
FACILITY NAME:FLORENCE RESIDENTIAL CARE HOME #2FACILITY NUMBER:
430707868
ADMINISTRATOR:PERLA DIMALANTA ZEIJNALIFACILITY TYPE:
735
ADDRESS:135 NORTH 8TH STREETTELEPHONE:
(408) 293-0362
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:10CENSUS: 9DATE:
03/17/2025
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Care Staff Winnie Rodriquez TIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Facility bathroom has mold, mildew, and a clogged sink.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Care Staff Winnie Rodriquez who called Administrator Perla Zeijnali. LPA Lund explained the reason for the visit to Administrator Perla Zeijnali who gave permission to Care Staff Winnie Rodriquez to sign required paperwork. Census: 9
Facility bathroom has mold, mildew, and a clogged sink- LPA Lund observed in the main facility bathroom to have mold and mildew in the shower and sink. LPA Lund did not observe a clogged sink. Administrator Perla Zeijnali is getting quotes on fixing the bathroom.
Based on LPA’s observations and interview with Administrator Perla Zeijnali, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
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 4
Control Number 26-AS-20220607120058
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: FLORENCE RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 430707868
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2025
Section Cited
CCR
80087(a)
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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.This requirement is not met as evidenced by:
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Administrator Perla Zeijnali is getting quotes on fixing the bathroom
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LPA Lund observed in the main facility bathroom to have mold and mildew in the shower and sink. Which poses a potential 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: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
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
06/07/2022 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 26-AS-20220607120058

FACILITY NAME:FLORENCE RESIDENTIAL CARE HOME #2FACILITY NUMBER:
430707868
ADMINISTRATOR:PERLA DIMALANTA ZEIJNALIFACILITY TYPE:
735
ADDRESS:135 NORTH 8TH STREETTELEPHONE:
(408) 293-0362
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:10CENSUS: 9DATE:
03/17/2025
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Care Staff Winnie Rodriquez TIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff makes resident feel uncomfortable.
Facility is not enforcing mask wearing requirement.
Staff serving food that is not of quality.
Staff not washing hands in between serving meals to residents.
Staff utilizing resident's personal item without permission.
INVESTIGATION FINDINGS:
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Staff makes resident feel uncomfortable - LPA Lund interviewed staff, and clients in care. Based interviews with current staff and clients in care. Client’s feel comfortable at the facility and staff do not make them feel uncomfortable.

Based on interviews with current staff and clients in care, on the information provided, it was unclear if staff makes resident feel uncomfortable, therefore the allegation was deemed UNSUBSTANTIATED.

Facility is not enforcing mask wearing requirement - LPA Lund reviewed the facility mitigation plan, interviewed staff, and clients in care. Based interviews with current staff and clients in care. When LPA Lund arrived staff Care Staff Winnie Rodriquez was wearing mask and gloves due three clients have COVID 19. Staff. The facility has a mitigation plan for COVID 19.

Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
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-20220607120058
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: FLORENCE RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 430707868
VISIT DATE: 03/17/2025
NARRATIVE
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Based reviewed facility mitigation plan interviews with current staff and clients in care, on the information provided, it was unclear if facility is not enforcing mask wearing requirement, therefore the allegation was deemed UNSUBSTANTIATED.

Staff serving food that is not of quality - LPA Lund reviewed facility menu, interviewed staff, and clients in care. Based facility records review, interviews with current staff and clients in care. Clients interviewed stated that the food is good. Staff interviewed stated the food quality is good and had no complaints about the food.

Based on facility records review, interviews with current staff and clients in care., on the information provided, it was unclear if staff serving food that is not of quality, therefore the allegation was deemed UNSUBSTANTIATED.

Staff not washing hands in between serving meals to residents - LPA Lund reviewed the facility mitigation plan, interviewed staff, and clients in care. Based facility records review, interviews with current staff and clients in care. Clients interviewed stated that have seen staff washing their hands. Staff interviewed stated they wash their hands between serving meals to clients in care.

Based on facility menu, interviews with current staff and clients in care., on the information provided, it was unclear if staff not washing hands in between serving meals to residents, therefore the allegation was deemed UNSUBSTANTIATED.

Staff utilizing resident's personal item without permission - LPA Lund interviewed staff, and clients in care. Based interviews with current staff and clients in care. Clients interviewed stated that staff do not use clients’ personal items. Staff interviewed stated that they do not use clients’ personal items.

Based on interviews with current staff and clients in care, on the information provided, it was unclear if staff utilizing resident's personal item without permission, therefore the allegation was deemed UNSUBSTANTIATED.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. If the cited deficiency is not corrected by the noted due date; civil penalties may be assessed. The Facility Designee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4