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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200459
Report Date: 04/03/2024
Date Signed: 04/03/2024 10:38:32 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/15/2021 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210915083723
FACILITY NAME:HOMELIFE RESIDENTIAL CAREFACILITY NUMBER:
435200459
ADMINISTRATOR:JAVIER, JULIUS ERVINFACILITY TYPE:
735
ADDRESS:367 FONTANELLE DRIVETELEPHONE:
(408) 578-6257
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY:6CENSUS: 6DATE:
04/03/2024
UNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Joseph MercadoTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not follow emergency intervention plan
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 4/3/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint inspection. LPA met with Facilty Staff Joseph Mercado and explained the purpose of the visit.

During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility.

On 09/15/2021, the Department received a report alleging that staff does not follow emergency intervention plan.

The Department conducted interviews and record reviews. Based on the information available, it was unable to prove whether the staff did not follow emergency intervention plan.

Although the allegation 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 above allegation is unsubstantiated, at this time.

No deficiencies were cited during the visit. Report is reviewed and copy is provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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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