430708478-3-14-2025-26-AS-KHOS-DFHT9R-20250407143223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708478
Report Date: 03/14/2025
Date Signed: 03/14/2025 03:40:44 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
03/07/2025 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20250307092311

FACILITY NAME:	SANTO NINO RESIDENTIAL CARE HOME #1		FACILITY NUMBER:	430708478
ADMINISTRATOR:	DHORYDELL SISON		FACILITY TYPE:	740
ADDRESS:	105 CLAYTON AVENUE		TELEPHONE:	(408) 295-4112
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95110
CAPACITY:	6	CENSUS:	DATE:	03/14/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Licensee Teodora Sison		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are not addressing bedbugs in the facility

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter arrived unannounced to deliver the findings of a complaint investigation. LPAs met with Licensee Teodora Sison and stated the purpose of the visit.

On 3/13/2025, the Department initiated the complaint investigation. During the investigation LPAs toured resident’s bedroom 1 to 3. LPAs inspected all resident bed sheets and observed small dark spots, black in color and reddish, rusty stains on the sheets. Powder residue was observed on the baseboard and on floors of 3 out of 3 resident bedrooms, which ADM stated they recently had the place fumigated due to the bedbugs infestation.

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

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-20250307092311

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SANTO NINO RESIDENTIAL CARE HOME #1	FACILITY NUMBER: 430708478
	VISIT DATE: 03/14/2025

NARRATIVE

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LPA Partoza interviewed 3 residents and ADM. R1, R2 and R4. 1 out of 3 stated he/she have rashes but cannot identify if it is a bedbug bite. 1 out of 3 stated, he/she has rashes and showed the rashes to LPAs. 1 out of 2 stated he/she does not have any rashes or bedbug bites. ADM stated, the facility currently has called the exterminator and the place was treated for bedbugs on 3/10/2025. ADM stated the bedcovers were not replaced and the black spots were residue of bedbug’s eggs after the fumigation.

On 3/14/2025, LPAs interviewed R3 who stated he/she has observed bedbugs in her bedroom.

LPAs also toured bedroom 2. LPAs opened a dresser top drawer next to R5s bed and observed a bedbug inside the drawer (photograph taken). LPA inspected resident's R3' mattresses and observed 2 bedbugs on R3s bed sheets (photograph taken).

Based on observation, interview and record review, the preponderance of evidence has been met and the allegation has been SUBSTANTIATED.

A deficiency is being issued during today’s visit based on California Code of Regulations (CCR) Title 22. See LIC 9099D. An exit interview was conducted with Licensee Teodora Sison. A copy of the report and appeals rights were provided.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250307092311

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SANTO NINO RESIDENTIAL CARE HOME #1	FACILITY NUMBER: 430708478
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/15/2025 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated they will submit a written plan of action on how they will ensure resident's bedrooms are free from bedbugs. Licensee/ADM will seek professional help if the issue cannot be addressed. Licensee stated they will submit the written plan of action to the Department by POC due date 3/15/2025.
	8 9 10 11 12 13 14	Based on observation, record review and interview the licensee did not ensure resident's bedroom and furnishings were free from bedbugs, which poses an immediate health, safety and personal rights risk to 4 residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC9099 (FAS) - (06/04)

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