435200157-10-12-2023-26-AS-KHOS-CXASP8-20231105130240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200157
Report Date: 10/12/2023
Date Signed: 10/12/2023 09:43:46 AM

Unsubstantiated

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
03/29/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230329161259

FACILITY NAME:	SANDY'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	435200157
ADMINISTRATOR:	ZIPAGAN, AZUCENA		FACILITY TYPE:	740
ADDRESS:	550 TUSCARORA DRIVE		TELEPHONE:	(408) 472-2059
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 3	DATE:	10/12/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	ZIPAGAN, AZUCENA		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Staff are using locks as restraints for the residents while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of this complaint investigation. LPA met with Licensee, Azucena “Sandy” Zipagan. On 03/29/2023, the Department received a complaint alleging staff are using locks as restraints for the residents. It was alleged that the resident’s bedroom doors had the ability to be key locked from the outside of the room and the residents does not have capability to unlock the door from the inside. It was also alleged that staff lock the residents’ doors at night to let staff sleep. On 04/05/2023, the initial complaint investigation was conducted.

During the initial investigation, LPA Dolores observed all the resident bedroom doorknobs. Based on observation, all the resident bedrooms contained a “panic proof” doorknob with the ability to be locked from the inside. The door can be easily unlocked by turning the doorknob from the inside of the bedroom. The outer part of the doorknob facing the common area requires a key. Facility staff have a key to each bedroom. SEE LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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-20230329161259

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: SANDY'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 435200157
	VISIT DATE: 10/12/2023

NARRATIVE

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Based on interview with the Licensee, the panic proof doorknobs were implemented about two weeks ago from 04/05/2023. A different set of doorknobs were installed after the HCBS final rule was implemented, which was observed by another State agency. The set of doorknobs observed by another State agency were not a “panic lock” and required the residents to unlock the door by turning the button from the inside. The staff had a key to each bedroom. Licensee states there are / were no residents being locked in their bedrooms during the night. The facility does not have a resident who has wandering behaviors.

Based on interview with the staff (S2), the facility does not have a resident with wandering behavior during any time of the day. S2 states none of the residents are being locked in their bedrooms but the residents can lock their doors for privacy if they want. S2 states the staff has a key to each bedroom in case of an emergency. The facility has live-in staff on premises and the residents know where the staff resides in case they need anything during the night. Residents are also being checked on during the nighttime.

Based on resident interviews, R2 states to have never been locked out of his/her room or locked in his/her room. R1 was able to communicate with LPA but was unable to answer the questions asked. Two residents (R1 – R2) successfully demonstrated how to unlock their bedroom door.

The review of resident records shows that R1 – R3 does not have wandering behavior and are able to follow instructions. Correspondence shows the facility was in contact with another State agency regarding guidance on the implementation of locked doorknobs in the resident’s bedrooms. The facility was asked to place the lock doorknobs back to be in HCBS compliance.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee, Azucena “Sandy” Zipagan and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

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