435200383-7-25-2025-26-AS-CKAI-DPLPU3-20251222103652

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200383
Report Date: 07/25/2025
Date Signed: 07/25/2025 04:40:22 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
05/28/2024 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20240528090232

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: 7	DATE:	07/25/2025
		UNANNOUNCED	TIME BEGAN:	03:35 PM
MET WITH:	Anthony Miller		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff do not treat residents with dignity or respect
Staff do not keep the facility clean or sanitary
Staff are mismanaging client appointments
Staff prohibit over the counter vitamins authorized by the client's doctor.
Staff do not provide consistent rules for residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Anthony Miller. On 05/28/2025, the department received a complaint with the above allegations. LPA Marrufo conducted an initial complaint investigation visit on 06/05/2024. LPA Marrufo conducted additional complaint investigation visits on 08/13/2024 and 08/21/2024.

LPA Marrufo interviewed four residents on 08/13/2024 and three residents on 08/21/2024. Seven out of seven interviewed residents stated to have not observed staff S1 or S2 speak inappropriately to residents.

On 06/05/2024, LPA Marrufo interviewed S1 and two other staff. On 08/21/2024, LPA Marrufo interviewed four staff. During interviews S1 stated to not speak inappropriately to residents. The six other interviewed staff stated to have not observed S1 speak inappropriately to residents. S1 and five out of the six interviewed staff stated to have not observed S2 speak inappropriately to residents. See LIC9099-C page for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025

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-20240528090232

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: 07/25/2025

NARRATIVE

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One out of the six interviewed staff stated to not work on the same shift as S2.

On 07/25/2025, LPA Marrufo conducted an interview with S2. S2 stated to have never spoken inappropriately to any residents.

LPA Marrufo obtained a copy of the Client Responsibilities and House Expectations form, which states, “Complete assigned house chores at the scheduled times…After enjoying a meal, please help with the clean up…Wash or put in the dishwasher dishes, glasses, utensils, and other kitchen items you use.”

Six out of seven interviewed residents stated to have not observed the facility to be dirty or unsanitary. One out of seven interviewed residents stated to have observed the showers remain dirty but has observed dishes to be cleaned and the rest of the facility to be clean.

Seven out of seven interviewed staff stated to not observed the facility to be dirty or unsanitary.
During visit on 06/05/2024, LPA toured the facility. LPA observed the first-floor bathroom to have clean floors and a clean shower, except for some streaks on the glass shower stall. The upper floor women’s bathroom had towels on the floor and the glass shower stall had some streaks. The upper floor men’s bathroom had a clean floor and the glass shower stall had some streaks. The beds in all resident bedrooms were made. The ground floor living room had a clean floor and was organized. LPA Marrufo observed cleaning supplies in the kitchen area and basement. The hallway had a locked storage closet that contained cleaning chemicals inside. There was a whiteboard with a resident chore schedule in the hallway.

Six out of seven residents stated to have not experienced staff mismanaging client appointments. One out of seven residents, R1, stated to have experienced needing to reschedule an appointment because staff failed to provide transportation.

Seven out of seven interviewed staff stated to have not observed staff mismanaging client appointments. LPA Marrufo also interviewed S3, Resident Director of Operations. S3 stated that the facility does not have a policy on appointments and transportation. S3 stated residents are expected to take themselves to appointments. S3 stated that R1 refused to attend the appointment that R3 claimed to have missed. Page 2 of 3.

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240528090232

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: 07/25/2025

NARRATIVE

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LPA Marrufo obtained a copy of resident R2’s Centrally Stored Medication and Destruction Record (CSMDR). R2’s CSMDR indicated three over-the-counter vitamins were prescribed to R2.

Seven out of seven interviewed residents stated staff do not prohibit over the counter vitamins authorized by the client’s doctor.

Seven out of seven staff stated staff do not prohibit over the counter vitamins authorized by the client’s doctor. Five out of seven interviewed staff stated that over the counter vitamins and supplements must be cleared with either the resident’s doctor or psychiatrist before the resident can be allowed to have them. The five interviewed staff stated that vitamins and supplements must be first cleared by resident doctors or psychiatrists to ensure the vitamins or supplements do not conflict with any of the resident’s currently prescribed medications.

Seven out of seven interviewed residents stated to have not experienced staff providing inconsistent rules for residents.

Seven out of seven interviewed staff stated staff to have not observed staff providing inconsistent rules for residents.

Based on information from interviews conducted with staff, 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 were cited under California Code of Regulations Title 22

This report was reviewed with Anthony Miller and a copy of this report was provided.

Page 3 of 3. END REPORT

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025

LIC9099 (FAS) - (06/04)

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