435200383-10-2-2024-26-AS-KHOS-DARLB2-20241106073601

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200383
Report Date: 10/02/2024
Date Signed: 10/02/2024 01:06:27 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
08/12/2024 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20240812091840

FACILITY NAME:	LA SELVA		FACILITY NUMBER:	435200383
ADMINISTRATOR:	JIM MILLSAP		FACILITY TYPE:	772
ADDRESS:	652 FOREST AVENUE		TELEPHONE:	(650) 323-1401
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94301
CAPACITY:	12	CENSUS:	DATE:	10/02/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Michelle Ly		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff did not follow client’s care plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Michelle Ly, Director of Residential Admissions. On 08/12/2024, the Department received a complaint with the above allegation. On 08/21/2024, LPA Marrufo conducted an initial complaint investigation visit. An additional complaint investigation visit was conducted on 09/11/2024.

LPA Marrufo obtained copies of the following records during the investigation: R1’s Residential Progress Notes, R1’s Admission Agreement, R1’s Appraisal/Needs and Services Plan, Client Responsibilities and House Expectations, R1’s La Selva Dually Diagnosed Track Requirements, and an email communication with staff S1.

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: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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-20240812091840

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: LA SELVA	FACILITY NUMBER: 435200383
	VISIT DATE: 10/02/2024

NARRATIVE

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R1’s Admission Agreement indicates R1 was admitted to the facility on 05/10/2023. The email communication with staff S1 indicates R1 was discharged from the facility on 06/26/2023.

LPA Marrufo reviewed R1’s Residential Progress Notes. R1’s Progress Notes have entries dated from 05/10/2023 to 06/26/2023. Each daily Residential Progress Note from 05/10/2023 until 06/24/2023 showed that R1 neither reported nor was observed to have had a suicidal ideation. R1’s Residential Progress Note for 06/25/2023 does not indicate whether R1 reported or was observed to have had a suicidal ideation. R1’s Residential Progress Note from 06/26/2023 at 1:27 PM states that R1 did not report nor was observed to have had a suicidal ideation. R1’s Progress Note from 06/26/2023 at 5:30 PM states R1 felt ready to move to the next facility. The note states R1 reported some continued daily passive suicidal ideation and denied current intent. The note also states R1 denied self-harm urges.

During visit on 10/02/2024, LPA Marrufo interviewed S1. S1 stated that passive suicidal ideation is when an individual has thoughts of suicidal ideation but does not have a plan. LPA Marrufo asked S1 why the last entry of R1’s Residential Progress Notes state that R1 had continued suicidal ideation, but all the previous entries state that R1 neither reported nor was observed to have had suicidal ideation. S1 stated that S1 could only guess that perhaps R1 had a different relationship to the staff who wrote the last entry in R1’s Residential Progress Notes than R1 had with the staff who wrote the other entries.

During visit on 10/02/2024, LPA Marrufo interviewed S2. During interview, S2 stated that the facility where R1 was being transferred to on 06/26/2023 is an independent living facility for men. S2 stated the independent living facility allows the admittance of residents who express passive suicidal ideation, but not active suicidal ideation. S2 stated that La Selva also only permits residents with passive suicidal ideation and if a resident is found to have active suicidal ideation, then the resident would be hospitalized.

R1’s Admission Agreement does not make any mention of drug testing of residents.

R1’s La Selva Dually Diagnosed Track Requirements document states that one of the requirements includes “Random drug tests while at the program via U.A. test.”

Page 2 of 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240812091840

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: LA SELVA	FACILITY NUMBER: 435200383
	VISIT DATE: 10/02/2024

NARRATIVE

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S1’s email states that R1 did not undergo any drug tests while admitted to the facility.

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

No Deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with Michelle Ly and a copy of this report was provided.

Page 3 of 3.

END REPORT

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

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