435200383-11-1-2024-26-AS-KHOS-DAXN68-20241112091041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200383
Report Date: 10/09/2024
Date Signed: 11/01/2024 11:53:19 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
09/30/2024 and conducted by Evaluator Kiran Jain

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20240930115429

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: 8	DATE:	10/09/2024
		UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Michelle Ly & Anthony Miller		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility staff are not properly addressing bed bugs in the facility.
Facility is not clean, safe, sanitary and in good repair at all times for the safety and well-being of clients.

INVESTIGATION FINDINGS:

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*** This is an amended report ***
On 10/09/24, Licensing Program Analysts (LPAs) Grace Donato & Kiran Jain conducted an unannounced complaint investigation visit. LPAs met with Michelle Ly, Director of Admissions, and Anthony Miller, Director of Operations and LPAs explained the purpose of the visit.

Regarding the allegation Facility staff are not properly addressing bed bugs in the facility, Reporting Party (RP) stated that a resident (R1) woke up in the morning and found an adult bed bug under the pillow.
Based on observations, during the visit, LPAs toured the facility and inspected the beds and mattresses and found no evidence of bed bugs.

LPAs interviewed 2 staff members (S1) and (S2), and they mentioned that when residents bring up bed beg complaints, they act on it immediately and schedule earliest possible pest control service. LPAs also interviewed the Terminix technician (T1), who confirmed that they inspected for the bed bugs during 10/01/24 visit and the technician verbally confirmed over the telephone that they didn’t find any bed bugs.
Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

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-20240930115429

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: 10/09/2024

NARRATIVE

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Based on records review, after the bed bug incident was reported to the staff, the facility requested an earliest bed bug inspection through the contracted services of a pest control company, who come to the facility every month for pest control. Based on pest control’s summary report, there were no pests found. As per this report, a follow-up inspection is still due. Based on email communication obtained the facility requested the earliest appointment they could get from pest control, which was on 10/1/2024 between 3pm – 5 pm. LPAs also obtained a service report for the date of service 10/1/24 from the facility.

Regarding the allegation Facility is not clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, RP stated that R1 observed that the house was dirty and in need of a deep cleaning. R1 mentioned finding fingernail clippings on the carpet by the bed from a previous resident.

Based on observations, LPAs found facility to be in good condition. Beds were properly made, bathrooms, kitchen, dining table and chairs were clean. As per the facility program, residents are assigned chores like, cleaning, meal prepping, cooking, grocery etc. The facility offers housekeeping on as need basis and was last cleaned on 10/04/2024.

Based on interviews, observation, and record reviews, the department has determined that although the allegations 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 allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

LIC9099 (FAS) - (06/04)

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