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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200432
Report Date: 11/22/2021
Date Signed: 11/23/2021 08:39:53 AM

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
08/06/2021 and conducted by Evaluator Steve Nguyen
COMPLAINT CONTROL NUMBER: 26-AS-20210806095724
FACILITY NAME:CARRANZA #1FACILITY NUMBER:
435200432
ADMINISTRATOR:CARRANZA, EDUARDOFACILITY TYPE:
735
ADDRESS:2052 LADDIE WAYTELEPHONE:
(408) 809-4715
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 5DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Ernie ManaoisTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Client is not provided with meal service that meets client's needs
Client is not provided with clean linens and mattress
Facility has bed bugs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Nguyen arrived unannounced to deliver the complaint investigation finding. LPA met with Administrator, Ernie Manaois, and explained the purpose of the visit.

On 08/06/2021 the Department received a complaint regarding the above allegations.

On 08/16/2021 LPA Marybeth Donovan, opened the unannounced 10-day Complaint investigation and advised the Administrator that the Department would be conducting the investigation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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 2
Control Number 26-AS-20210806095724
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: CARRANZA #1
FACILITY NUMBER: 435200432
VISIT DATE: 11/22/2021
NARRATIVE
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Between 08/10/2021 and 11/21/2021, the Department: interviewed the Administrator, 1 staff and 2 residents. Records reviewed includes but are not limited to: physician's report and appraisal needs and services plan, pest control quotes on 8/13/2021, receipts on 8/18/2021 for linens, bedding and mattresses purchased and August 2021 menu.

2 out of 2 staff denied all allegations: all stated that facility took immediate action upon discovery of bed bugs. Cleaning process included but not limited to: Cleaning, washing, replacing comforters, linens and mattresses, contacting Orkon Pest Control Service. All staff stated that linens are washed weekly and that mattresses are inspected regularly or as needed. All staff declared that the facility adhered to the weekly menu to provide healthy and safe foods for client consumption.

Based on information from interviews conducted 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 violation 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, Ernie Manaois, and a copy of this report provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2