435200335-11-22-2024-26-AS-KHOS-DBTJ5P-20241210054505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200335
Report Date: 11/22/2024
Date Signed: 11/22/2024 03:44:21 PM

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
09/27/2022 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20220927091401

FACILITY NAME:	TERESA RESIDENTIAL CARE HOME		FACILITY NUMBER:	435200335
ADMINISTRATOR:	ALLAN G. CEASE		FACILITY TYPE:	735
ADDRESS:	3298 ARQUEADO DRIVE		TELEPHONE:	(408) 532-1376
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY:	6	CENSUS: 4	DATE:	11/22/2024
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Melda Antonio		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff not responsive to communication from hospital regarding resident's discharge.
Staff not able to redirect resident with behaviors.

INVESTIGATION FINDINGS:

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LPA Marrufo conducted an unannounced complaint investigation visit and met with Melda Antonio, Administrator. On 09/27/2022, the Department received a complaint with the above allegations. On 10/03/2022, LPA Marrufo conducted an initial complaint investigation visit. On 11/01/2024, LPA Marrufo conducted an additional complaint investigation visit.

A witness stated during interview that the facility sent resident R1 to Emergency Psychiatric Services (EPS) for a psychiatric hold on 09/24/2022. The witness stated that on 09/25/2022 at 5:00 AM R1 was ready to be discharged from EPS and EPS staff made multiple attempts to contact facility staff throughout the day. The witness stated that on 09/26/2022 at 10:00 AM a facility staff picked up R1 from EPS.

See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

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 3

Control Number 26-AS-20220927091401

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: TERESA RESIDENTIAL CARE HOME	FACILITY NUMBER: 435200335
	VISIT DATE: 11/22/2024

NARRATIVE

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On 11/01/2022, the Department received a cross-report stating that facility staff took R1 to EPS on 10/30/2022. The cross-report stated that on 10/31/2022 EPS staff contacted facility staff S1, who stated R1 is not allowed back to the facility. The cross-report stated S1 admitted having not issued an eviction notice to R1. The cross-report stated that S1 advised EPS staff to contact R1’s Case Manager, CM1. The cross-report stated that EPS staff attempted to call CM1, but CM1’s voicemail stated CM1 would be out of the office until 11/01/2022.

LPA Marrufo received an email on 11/05/2024 from R1’s current Case Manager, CM2. The email stated that R1 was admitted to EPS on 09/19/2022 and discharged on 09/20/2022 and 09/23/2022 and discharged on 09/24/2022. The email stated to not have any admission or discharge information from EPS.

R1’s Individual Program Plan (IPP) states that R1 is verbal, but usually speaks off-topic and can be difficult for others to understand.

On 10/03/2022, LPA Marrufo interviewed staff S2-S3 and Licensee Maria Sanchez. S2 stated that staff brought R1 to EPS on 09/23/2022 at around 6:00 PM. S2 stated EPS staff called the facility on 09/24/2022 and staff picked up R1 that day around 2:30 PM. S2 stated to have left the Administrator’s telephone number, the facility home telephone number, and S2’s telephone number with EPS to be able to reach the staff once R1 was ready to be discharged from EPS.

S3 stated that staff are available over the weekends to pick up residents from EPS.

Licensee Maria Sanchez stated to provide EPS with the facility home telephone number. Licensee stated that she and her husband responsible for picking up residents from EPS when EPS contacts the facility upon discharge of the resident.

R1’s IPP states on page 8, “RCH staff will ensure customer’s safety by providing ongoing supervision and provide intervention as needed to prevent aggression towards others” and on page 10 it states, “Teresa RCH staff will intervene and redirect [R1] to another activity when [R1] escalates to aggressive behaviors. Staff will monitor and collect data daily.”

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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220927091401

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: TERESA RESIDENTIAL CARE HOME	FACILITY NUMBER: 435200335
	VISIT DATE: 11/22/2024

NARRATIVE

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During visit on 11/01/2024, LPA Marrufo interviewed S2, who stated that staff kept daily logs for R1 while R1 was a resident at the facility. S2 stated staff received training from a behaviorist on how to intervene with and redirect R1. S2 stated that if R1 was attacking other residents, staff would move the other residents away from R1. S2 stated S2 would talk to R1 and hug R1 when R1 was being aggressive towards others.

On 11/11/2024, LPA Marrufo obtained copies of Crisis Intervention Training Certificates for staff S2, S3, and another staff. The training certificates were dated 07/12/2022.

During interview on 10/03/2022, S2 stated that staff contacted R1’s doctor and psychiatrist to change R1’s medications on 06/14/2022 and 06/21/2022. S3 stated on 10/03/2022 that R1’s medication had been changed many times.

Based on information from interviews conducted with staff and witnesses, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Administrator Melda Antonio and a copy of this report was provided.

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END REPORT

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC9099 (FAS) - (06/04)

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