435200281-10-18-2024-26-AS-KHOS-DABRDF-20241023125550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200281
Report Date: 10/18/2024
Date Signed: 10/18/2024 05:21:42 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
09/29/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20230929131152

FACILITY NAME:	DRY CREEK GUEST HOME		FACILITY NUMBER:	435200281
ADMINISTRATOR:	IGNACIO, ESTHER L.		FACILITY TYPE:	740
ADDRESS:	1856 DRY CREEK ROAD		TELEPHONE:	(408) 559-6010
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	6	CENSUS: 4	DATE:	10/18/2024
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Ven Ignacio		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff is not fingerprint cleared.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Licensee (LCN) Ven Ignacio.

On 9/29/2023, the Department received a complaint with the allegations that facility staff is not fingerprint cleared.

On 10/6/2023, the Department conducted an initial investigation visit. LPA interviewed 4 staff, 5 resident, and 2 family members. LPA requested client roster, LIC500, resident physician report and appraisal Needs and Service Plan.

Continue on LIC9099-C. Page 1 of 2..

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

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 9

Control Number 26-AS-20230929131152

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: DRY CREEK GUEST HOME	FACILITY NUMBER: 435200281
	VISIT DATE: 10/18/2024

NARRATIVE

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Facility staff is not fingerprint cleared:
The allegation is that a relative of Licensee(LCN) and Administrator (ADM) lives in the facility without fingerprint clearance and help to take care of resident.

On 10/6/2023, LPA interviewed Licensee (LCN) Ven Ignacio. LCN stated the relative of LCN and ADM lives in the facility without fingerprint clearance but the relative is not staff to take care of resident.

LPA checked facility personnel report summary and Guardian system, and was unable to find the name of LCN's relative FM who lives in the facility. LPA found staff S2 was not associated with the facility. LCN stated S2 just works for the facility for one and half months and the facility is preparing the document to associate S2 with the facility. LPA told LCN that staff need to associated with the facility prior to work for the facility.

Based on the interviews and record reviewed, FM lives in the facility without fingerprint clearance and staff S2 to work for the facility before S2 was associated with the facility.

The Department has investigated the above allegations. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Citations were noted today. Please see LIC9099-D. Appeal right was provided. Exit interview was conducted with LCN. A copy of the report was provide to LCN.

Page 2 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 26-AS-20230929131152

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: DRY CREEK GUEST HOME	FACILITY NUMBER: 435200281
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/19/2024 Section Cited CCR 87411(c)(3)(D)	1 2 3 4 5 6 7	87355 Criminal Record Clearance (e) All individuals subject to a criminal record review shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)	1 2 3 4 5 6 7	Licensee stated to provide a plan of correction by the POC due date to make sure all staff are associated with the facility prior to work for the facility.
	8 9 10 11 12 13 14	The requirement was not met as evidenced by: Base on interviews and record reviewed, staff S2 works for the facility for one and half months prior to associate with the facility. Licensee S2 worked for the facility before but does not associate with the facility at this time. That poses/posed a immediate health, safety risk to persons in care.	8 9 10 11 12 13 14
Type A 10/19/2024 Section Cited CCR 87355(e)(1)	1 2 3 4 5 6 7	87355 Criminal Record Clearance (e) All individuals subject to a criminal record review shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department	1 2 3 4 5 6 7	Licensee stated to submit a plan of correction by the POC due date to ensure all the staff and all the people live in the facility to have criminal clearance and are associated with the facility.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review and interviews, S2 worked at the facility and the licensee's relatives live in the facility without fingerprint clearance which poses an immediate health, safety risk to a person in care.	8 9 10 11 12 13 14

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: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 9

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
09/29/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20230929131152

FACILITY NAME:	DRY CREEK GUEST HOME		FACILITY NUMBER:	435200281
ADMINISTRATOR:	IGNACIO, ESTHER L.		FACILITY TYPE:	740
ADDRESS:	1856 DRY CREEK ROAD		TELEPHONE:	(408) 559-6010
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	6	CENSUS: 5	DATE:	10/18/2024
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Ven Ignacio		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff administering medications without training.
Facility staff did not seek medical attention in a timely manner.
Resident left facility unassisted due to lack of supervision.
Facility is not adhering to physician's order for special diet.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Licensee (LCN) Ven Ignacio.

On 9/29/2023, the Department received a complaint with the above allegations.

On 10/6/2023, the Department conducted an initial investigation visit. LPA interviewed 4 staff, 5 resident, and 2 family members. LPA requested client roster, LIC500, resident physician report and appraisal Needs and Service Plan.

Continue on LIC9099-C. Page 1 of 4..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 9

Control Number 26-AS-20230929131152

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: DRY CREEK GUEST HOME	FACILITY NUMBER: 435200281
	VISIT DATE: 10/18/2024

NARRATIVE

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Facility staff administering medications without training:
The allegation is that staff administering medications to residents without training.

On 10/6/2023, LPA interviewed Licensee (LCN) Ven Ignacio, Administrator (ADM), and staff S1, 3 Out of 3 stated LCN, ADM, S1, and staff S2 administer medications to residents.

LPA interviewed staff S2, S2 stated he/she administers medications to residents.

LPA requested medication training document for LCN, ADM, S1, and S2. LCN provided LCN, ADM and S1's medication training document. LCN was unable to provide staff S2's medication training document. S2 stated he/she received medication training. LCN and ADM stated S2 received medication training.

Based on the interviews and records reviewed, facility staff S2 administers medications to residents but was unable to provide the medication training document. LCN, ADM and S2 stated S2 received medication training. LCN stated medication training was provided to staff S2, but LCN was unable to provide the document.

Facility staff did not seek medical attention in a timely manner:
The allegation is that resident R1 had a fall but the facility did not send R1 to hospital.

On 10/3/2024, LPA interviewed LCN. LCN stated around May 2023, resident R2 had a fall. LCN stated he/she wanted to send R2 to hospital to check but R2 refused. LCN stated R2 stated it was not serious. LCN stated R2 did not want the facility to contact R2's family member (FM). LCN stated R2 did not want to see FM. LCN stated he/she called R2's family member (FM2), POA of R1 and R2, to discuss the situation of R2's fall and FM2 agreed with R2's decision. LCN stated several days later, FM visited the facility and decided to send R2 to hospital to check.

LPA interviewed ADM. ADM stated he/she cannot recall any incident that needed to call 911 but the facility did not call 911.

Continue on LIC9099-C. Page 2 of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 26-AS-20230929131152

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: DRY CREEK GUEST HOME	FACILITY NUMBER: 435200281
	VISIT DATE: 10/18/2024

NARRATIVE

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LPA interviewed Resident R2. R2 stated he/she did not think that she needed to be sent to hospital at that time and he/she refused to be sent to hospital. LPA interviewed FM2, R2's POA. FM2 stated he/she was notified by the facility for the incident, and he/she agreed that R2 did not need to send to hospital. Both R2 and FM2 stated the allegation is not true.

Resident left facility unassisted due to lack of supervision:

The allegation is that resident R1 left the facility without assist due to lack of supervision.

On 10/6/2023, LPA interviewed Licensee (LCN). LCN stated around March 2023, resident R1 walked down the drive way to the entrance of the property and staff found R1 walking through the entrance. LCN stated staff followed R1 and took R1 back to the facility immediately. LCN stated R1 was away from the facility less than 1 house in the neighbor.

LPA interviewed resident R1. R1 stated he/she cannot recall if he/she walked out from the facility by himself/herself.

LPA interviewed Administrator (ADM), staff S1, and S2. All of them stated they cannot recall the facility has any elopement incident.

LPA interviewed resident R2, and R1 and R2's POA. R2 is R1's spouse. Both stated the allegation is not true.

Based on the interviews, there is no evidence to indicate resident left facility unassisted due to lack of supervision.

Continue on LIC(099-C. Page 3 of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 26-AS-20230929131152

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: DRY CREEK GUEST HOME	FACILITY NUMBER: 435200281
	VISIT DATE: 10/18/2024

NARRATIVE

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Facility is not adhering to physician's order for special diet:
The allegation is that the facility is not adhering to physician order for special diet. It was observed scrambling eggs, hot dog, cupcake with frosting and cup of fruit served as resident R1's breakfast.

On 10/6/2023, LPA interviewed Licensee (LCN). LCN stated he/she talked to R1's doctor regarding R1's diet. LCN stated the instructions are to reduce R1's food quantity consumption and to reduce sugar for R1. LCN stated he/she provides the instructions to all staff for R1's diet

LPA interviewed Administrator, staff S1 and S2. They all stated they follow LCN's instructions to provide food to R1.

LPA interviewed resident R2. R2 is spouse of R1. R2 stated the allegation is not true. R2 stated the facility staff check R1's blood sugar before each meal, and the facility staff check and control the food for R1 for each meal.

Based on the review of R1' physician report dated 8/11/2022, the physician order to have CCHO ( Consistent/Controlled Carbohydrate) Diet. A controlled carbohydrate diet means that meals contain carbohydrate rich foods in fairly equal amounts. That is, each meal has about the same amount of carbohydrate rich foods from day to day as do lunches and dinners. This consistency helps to control the blood sugar levels.

Based on the interviews and record reviews, no evidence to indicate facility is not adhering to physician's order for R1's special diet.

Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

No citations noted for today’s visit. Exit interview was conducted with LCN. A copy of this report was provided to LCN.
Page 4 of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 9

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
09/29/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20230929131152

FACILITY NAME:	DRY CREEK GUEST HOME		FACILITY NUMBER:	435200281
ADMINISTRATOR:	IGNACIO, ESTHER L.		FACILITY TYPE:	740
ADDRESS:	1856 DRY CREEK ROAD		TELEPHONE:	(408) 559-6010
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	6	CENSUS: 4	DATE:	10/18/2024
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Ven Ignacio		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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9

Facility is restricting visitors.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Licensee (LCN) Ven Ignacio.

On 9/29/2023, the Department received a complaint with the allegation that facility is restricting visitors..

On 10/6/2023, the Department conducted an initial investigation visit. LPA interviewed 4 staff, 5 resident, and 2 family members. LPA requested client roster, LIC500, resident physician report and appraisal Needs and Service Plan.

Continue on LIC9099-C. Page 1 of 2..

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 26-AS-20230929131152

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: DRY CREEK GUEST HOME	FACILITY NUMBER: 435200281
	VISIT DATE: 10/18/2024

NARRATIVE

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Facility is restricting visitors:

The allegation is that the facility asked residents R1 and R2's family member (FM) to leave the facility. R1 and R2 are spouses.

On 10/6/2023, LPA interviewed Licensee (LCN). LCN stated in end of September 2023, resident R2, R1's spouse, asked the facility to expel R1 and R2's family member (FM) from the facility. LCN stated he/she asked FM to leave the facility but did not force FM to leave the facility. LCN stated R1 and R2 want to sell R1 and R2's house which FM lives in the house. LCN stated FM asked R2 not to sell the house, but R2 refused. LCN stated R2 refuses to see FM. LCN stated FM turned to talk to R1. LCN stated R1 has neurocognitive impairment. LCN stated R2 asked the facility to expel FM because FM wanted R1 not to sell the house and R1 has neurocognitive impairment.

LPA interviewed resident R2. R2 confirmed he/she asked the facility to expel FM.

LPA interviewed R1 and R2's POA who stated he/she knew R2 asked the facility to expel FM, and R1 and R2's POA does not think facility is restricting visitors.

Based on the interview, R2 wants to sell R1's and R2's house and refused to see FM, and asked the facility to expel FM from the facility.

The Department has investigated the above allegations. Based on the investigation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview conducted with LCN. This report was provided to review and for signature. A copy of this report was provided to LCN.

Page 2 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC9099 (FAS) - (06/04)

Page: 9 of 9