435200320-5-26-2023-26-AS-RMAO-CSHS4H-20230605133242

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200320
Report Date: 05/26/2023
Date Signed: 05/26/2023 05:01:48 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/16/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20210816123556

FACILITY NAME:	PACE - MAHALO		FACILITY NUMBER:	435200320
ADMINISTRATOR:	AIDA URENA		FACILITY TYPE:	735
ADDRESS:	1720 MERRILL DRIVE		TELEPHONE:	(408) 475-3015
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	6	CENSUS: 5	DATE:	05/26/2023
		UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Naward Hernandez Smith		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff did not follow residents IPP.
Staff did not follow residents behavioral plan
Staff did not send eviction letter to authorized representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted a complaint investigation visit to deliver investigation findings. LPA met with administrator (ADM) Naward Hernandez Smith.

On 08/16/2021, the Department received a complaint regarding the above allegations. An investigation visit was conducted on 08/25/2021. ADM was interviewed, and executive director (ED) Kurt Ohlfs was interviewed on the phone. Physician report, Appraisal Needs and Services plan, IPP and behavioral plan were obtained. ADM sent the exit letter and incident reports to LPA via emails.

Continued, see LIC 9099-C. page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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 3

Control Number 26-AS-20210816123556

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PACE - MAHALO	FACILITY NUMBER: 435200320
	VISIT DATE: 05/26/2023

NARRATIVE

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Staff did not follow residents’ IPP:
Staff did not follow residents’ behavioral plan:

Administrator (ADM) and Executive Director (ED) stated that R1’s Individual Program Plan (IPP) and Behavioral Support Plan is being adhered to by staff in managing and monitoring R1’s aggressive behaviors. ADM and ED stated that they were working closely with R1’s behaviorist and responsible party having quarterly meetings to discuss R1’s progress based on data collected which has a tremendous contribution in determining alternatives intervention to reduce R1’s aggressive behavior.

ADM stated that due to COVID-19 pandemic restrictions and limitations, R1’s aggressive behavior has increased resulting to series of aggressive behaviors, wherein the facility also took extra measures to protect other residents in the facility.

The department obtained and reviewed R1’s incident reports from 01/2019 to 10/2022 wherein R1 exhibited aggressive behaviors.

ADM and ED denied allegations that the facility did not adhere to residents’ IPP and Behavioral Plan.

Based on interviews, and record reviews, 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 no preponderance of evidence to prove that the allegations did nor did not occur.

Staff did not send eviction letter to authorized representative.

Based on investigation interviews, ED issued a 30- day eviction letter to San Andreas Regional Center (SARC) on 10/20/2020 for R1. An eviction letter was issued due to R1's aggressive behavior. ED stated that SARC has agreed to assist in finding a suitable placement home for R1 who can meet R1’s care and supervision.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20210816123556

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PACE - MAHALO	FACILITY NUMBER: 435200320
	VISIT DATE: 05/26/2023

NARRATIVE

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ED stated that SARC has informed R1’s family about R1’s eviction letter. A copy of the eviction letter sent to SARC by ED was not received by R1’s responsible family. ED stated that the facility sent a letter via mail courier to SARC but not to the family.

ADM stated R1 moved out of the facility on 03/25/2021, after 5 months has passed when they issued R1’s eviction on 10/20/2020.

Based on the records reviewed, and interviews conducted, the 30 day eviction letter sent to SARC was not an eviction order, instead it was kind of requesting consultancy and help from SARC. SARC agreed with the facility's request, and help to search for a better place for R1.

The Department has investigated the above allegations. Based on interviews conducted and records reviewed, 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 allegations did or did not occur.

Exit interview conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC9099 (FAS) - (06/04)

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