435200605-1-2-2026-26-AS-RMAO-DQNVC5-20260125151834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200605
Report Date: 01/02/2026
Date Signed: 01/02/2026 11:27:53 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
11/10/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20251110131747

FACILITY NAME:	ATRIA WILLOW GLEN		FACILITY NUMBER:	435200605
ADMINISTRATOR:	GURSU, UGUR (KURT)		FACILITY TYPE:	740
ADDRESS:	1660 GATON DR		TELEPHONE:	(408) 266-1660
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	63	CENSUS: 45	DATE:	01/02/2026
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Administrator Kurt Gursu		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Staff handled residents in a rough manner
Residents are not accorded dignity in his/her personal relationships with staff
Staff is neglecting residents Activitys of Daily living.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Kurt Gursu.

On November 10, 2025 the Department received a complaint alleging Staff handled residents in a rough manner.

On November 18, 2025, LPA Manuel Monter interviewed residents R1-R9. Resident 7 Out of 9 Residents (R1-R7) stated they have never seen staff being rough with residents when providing care. 2 Out of 9 Residents (R8 & R9) were unable to provide any relevant information due to neurocognitive disorder.

LPA Manuel Monter interviewed Memory Care Director (MCD) Janice Lacambra. MCD stated she hasn’t seen any instance of a staff being rough with residents when providing care. Page 1 Out of 7

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

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 9

Control Number 26-AS-20251110131747

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 01/02/2026

NARRATIVE

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LPA Manuel Monter interviewed staff S1-S8. 8 Out of 8 Staff (S1-S8) stated they have never seen staff handling residents in a rough manner.

On December 5, 2025, LPA Manuel Monter interviewed residents R10-R12. 3 Out of 3 residents (R10- R12) stated they have not seen or heard about any instance of the staff handling residents in a rough manner.

On December 5, 2025, LPA Manuel Monter interviewed staff S9-S16. 4 Out of 8 Staff (S9 S14-S16) stated they haven’t seen any instance of staff being rough with residents when providing care.

S10 stated he/she has seen staff being rough with residents when proving care. S10 stated he/she has seen staff pulling the residents to hard and grabbing too hard. S10 stated its an ongoing issue that continues to occur. S10 stated he/she can’t say for certain who it was he/she observed since he/she has seen multiple staff being rough when providing care.

S11 stated he/she has seen staff S7 handling residents in a rough manner, every time he/she works at the facility. S11 stated S7 grabs residents and pulls their shirt or squeezes their arms with too much force. S11 stated when S7 is rough, the residents yell out “ouch”. S11 stated all of the staff are rough, stating, “its all of them.” S11 stated it happens anytime he/she notices the other staff giving care. S11 stated he/she has also seen the staff, when changing the residents will toss the residents, without a care. LPA asked a follow up questions regarding details of these events; but Staff S11 would only speak about the staff as a whole and didn’t provide a response.

Staff S12 and S13 stated they have seen S7 being rough with residents, by grabbing residents’ arms or shirt and pulling them with too much force. S12 and S13 stated after LPA’s visit, S7 has not been doing this since.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 26-AS-20251110131747

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 01/02/2026

NARRATIVE

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On December 5, 2025, LPA Manuel Monter interviewed Administrator (ADM) Kurt Gursu. ADM stated he has been dealing with staff in his memory care that are gossiping. ADM stated a staff member reported that staff S7 was being rough. ADM stated when he investigated, he found the resident in question and observed had no bruising or marks. ADM stated when he asked all the staff, none stated they observed this alleged abuse. ADM stated there were staff that heard about the allegation of S7 being rough, but only the staff member who reported it was the one who had allegedly observed it. ADM stated the issue is that his staff continues to gossip and claim that different groups of staff are rough or yelling. ADM stated the staff in the memory care have cliqued and are gossiping. ADM stated he has spoken to the staff, that if something does occur to tell him. ADM stated furthermore, there is some negativity between staff. ADM stated some of the staff don’t like S7 because of the way he/she presents him/herself.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

Residents are not accorded dignity in his/her personal relationships with staff

On November 10, 2025 the Department received a complaint alleging Residents are not accorded dignity in his/her personal relationships with staff. Its been alleged facility staff yell and are rude/make inappropriate comments to residents in care. It has also been alleged staff slam resident food trays.

On November 18, 2025, LPA Manuel Monter interviewed residents R1-R9. Resident 7 Out of 9 Residents (R1-R7) stated they have never heard staff saying inappropriate/rude comments or yell towards residents. Resident 7 Out of 9 Residents (R1-R7) stated they have never seen or heard about staff, when serving residents, slamming plates / cups when serving residents.

2 Out of 9 Residents (R8 & R9) were unable to provide any relevant information due to neurocognitive disorder.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 26-AS-20251110131747

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 01/02/2026

NARRATIVE

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LPA Manuel Monter interviewed Memory Care Director (MCD) Janice Lacambra. MCD stated she hasn’t heard or seen any staff saying inappropriate/rude comments towards residents. MCD stated she hasn’t heard or seen any staff yelling at residents. MCD stated she is on the floor Monday thru Friday and hasn’t heard or witnessed this. MCD stated she has never seen staff slamming plates or cups. MCD stated she is also on the floor during dining time. MCD stated she has never heard or seen this happen.

LPA Manuel Monter interviewed staff S1-S8. 8 Out of 8 Staff (S1-S8) stated they have never heard or seen any staff yelling at residents. 8 Out of 8 Staff (S1-S8) stated they have never heard or seen any staff saying inappropriate/rude comments towards residents. 8 Out of 8 Staff (S1-S8) stated they have never heard or seen staff slamming plates or cups.

On December 5, 2025, LPA Manuel Monter interviewed residents R10-R12. 3 Out of 3 Residents (R10-R12) stated they have never heard staff saying inappropriate/rude comments or yell towards residents. 3 Out of 3 Residents (R10-R12) stated they have never seen or heard about staff, when serving residents, staff slamming plates / cups when serving residents.

On December 5, 2025, LPA Manuel Monter interviewed staff S9-S16. 5 Out of 8 Staff (S9, S13 - S16) stated they have never heard or seen any staff yelling at residents. 5 Out of 8 Staff (S9, S13-S16) stated they have never heard or seen any staff saying inappropriate/rude comments towards residents. 6 Out of 8 Staff (S9,S10,S12,S14-S16) stated they have never seen or heard about staff, when serving residents, staff slamming plates / cups when serving residents.

S10 stated the care givers can be harsh. S10 stated he/she has seen the staff being aggressive and harsh when communicating with residents. S10 stated he/she has seen staff saying telling a resident that they are stupid. S10 stated this occurred in the independent side of the facility. S10 stated this occurred a few months ago. S10 stated there are multiple incidents that had occurred but can't remember the details.

S11 stated all the staff are rude and all the staff yell. S11 stated, “Yes, it’s all of them.” S11 stated the staff don’t care about the elderly population they are serving. S11 stated the way staff talks to residents is down to them and speaks to them in a disrespectful manner. S11 stated Staff S7 drops plates and cups in a slamming manner when serving residents. S11 stated S7 used to do that all the time, but since LPA’s visit, S7 is no longer slamming the plates and cups. Page 4 Out of 7

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 9

Control Number 26-AS-20251110131747

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 01/02/2026

NARRATIVE

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S12 stated S7 will yell at the residents, when its time for dinner stating, “what are you doing, its time for dinner.” S12 stated the way staff S7 communicates with residents is disrespectful and loud. S12 stated staff S7 yells at all the residents. S12 stated S7 will bring a residents meal to a resident and if a resident doesn’t want that choice or changes his/her mind, S7 will say, “you ordered that, so that’s what you’re eating.” S12 stated this was happening everyday, but since LPA’s visits, S7 has seemed to control him/herself.

S13 stated he/she has seen S7 once serve a resident coffee and he/she slammed the cup down and it spilled on a resident. S13 stated this happened only once.

On December 5, 2025, LPA Manuel Monter interviewed Administrator (ADM) Kurt Gursu. ADM stated his staff continues to gossip and claim that different groups of staff are yelling. ADM stated staff accuse each other of yelling. ADM stated furthermore, there is some negativity between staff. ADM stated some of the staff don’t like S7 because of the way he/she presents him/herself. ADM stated for example, the allegation of S7 yelling or other staff of yelling, management asks the accusers to explain. ADM stated the staff who make the accusations do not provide details and then recant. ADM stated he has never seen staff, when serving residents, staff dropping plates / cups when serving residents.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Staff is neglecting residents Activities of Daily living.

On November 10, 2025 the Department received a complaint alleging Staff is neglecting residents Activities of Daily living. It has been alleged facility staff ignore residents asking for help / deny residents meals. It has also been alleged residents have been left soiled and unchanged / residents were not assisted with mobility assistance/transfers.

Page 5 Out of 7

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 26-AS-20251110131747

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 01/02/2026

NARRATIVE

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On November 18, 2025, LPA Manuel Monter interviewed residents R1-R9. Residents 7 Out of 9 Residents (R1-R7) stated they have never observed staff ignoring residents asking for help. Residents 7 Out of 9 Residents (R1-R7) stated they have never seen facility staff deny residents meals. Residents 7 Out of 9 Residents (R1-R7) stated they have not observed any residents who were left soiled/unchanged. Residents 7 Out of 9 Residents (R1-R7) stated they have not observed residents who were not assisted with mobility assistance/transfers. 2 Out of 9 Residents (R8 & R9) were unable to provide any relevant information due to neurocognitive disorder.

LPA Manuel Monter interviewed Memory Care Director (MCD) Janice Lacambra. MCD stated she has never seen staff ignoring residents asking for help. MCD stated she has never seen staff denying residents meals. MCD stated she has never seen resident who were left soiled, neglected, un-showered or unchanged. MCD stated he/she has never witnessed this. MCD stated if she or staff observes that a resident is soiled, then the resident is changed right away. MCD stated she has never seen a resident who was neglected assistance with mobility assistance or transfers.

LPA Manuel Monter interviewed staff S1-S8. 8 Out of 8 Staff (S1-S8) stated they have never seen staff ignoring residents asking for help. 8 Out of 8 Staff (S1-S8) stated they have never seen staff denying residents meals. 8 Out of 8 Staff (S1-S8) stated they have never seen a resident who was neglected assistance with mobility or transfers. 7 Out of 8 Staff (S1-S4, S6-S8) stated they have never seen resident who were left soiled, neglected, un-showered or unchanged. Staff S5 stated he/she has in several occasions seen residents who were still soiled when he/she started his/her shift. S5 stated this occurs at least once a month. S5 stated he/she doesn’t know when he/she finds residents soiled if they were neglected.

On December 5, 2025, LPA Manuel Monter interviewed residents R10-R12. 3 Out of 3 Residents (R10-R12) stated they have never observed staff ignoring residents asking for help. 3 Out of 3 Residents (R10-R12) stated they have never seen facility staff deny residents meals. 3 Out of 3 Residents (R10-R12) stated they have not observed any residents who were left soiled/unchanged. 3 Out of 3 Residents (R10-R12) stated they have not observed residents who were not assisted with mobility assistance/transfers. Page 6 Out of 7

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 26-AS-20251110131747

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 01/02/2026

NARRATIVE

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On December 5, 2025, LPA Manuel Monter interviewed staff S9-S16. 6 Out of 8 Staff (S9 S12 - S16) stated they have never observed staff ignoring residents asking for help. 7 Out of 8 Staff (S9, S11 - S16) stated they have never seen facility staff deny residents meals. 6 Out of 8 Staff (S9 S12 - S16) stated they have not observed any residents who were left soiled/unchanged. 6 Out of 8 Staff (S9 S12 - S16) stated they have not observed residents who were not assisted with mobility assistance/transfers.

S10 stated he/she has observed residents left unattended in the activity room, and no staff were there or in the area. S10 stated this occurs in the memory care unit in the pm shift. S10 stated he/she has found residents soiled and wandering in the activity room. S10 stated he/she has seen the staff delay assistance to residents, stating they are doing something else. S10 stated he/she has seen residents left alone, who needed mobility assistance, who were neglected in the activity room of the memory care unit. S10 stated this happens anytime he/she see enters the memory care unit.

S11 stated staff will hide in the residents bedrooms and not provide care to the residents. S11 stated she has seen residents left soiled for an extended period whenever he/she does his/her rounds in the memory care unit. S11 stated he/she has found residents in their bedroom soiled and stated staff are not changing residents and leaving them soiled. S11 stated because the staff are avoiding work, they are also not assisting residents with mobility assistance or transfers. LPA asked S11 if he/she could provide any details regarding this. S11 stated its happening constantly and can’t bring up a specific example.
On December 5, 2025, LPA Manuel Monter interviewed Administrator (ADM) Kurt Gursu. ADM stated staff are not neglecting residents activities of daily living. ADM stated he has never seen staff ignoring residents who are asking for help and not providing care. ADM stated he has never seen a resident who was left soiled, neglected, un-showered or unchanged. ADM stated he has never seen staff neglecting residents with mobility assistance or transfers.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 7 Out of 7.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 7 of 9

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
11/10/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20251110131747

FACILITY NAME:	ATRIA WILLOW GLEN		FACILITY NUMBER:	435200605
ADMINISTRATOR:	GURSU, UGUR (KURT)		FACILITY TYPE:	740
ADDRESS:	1660 GATON DR		TELEPHONE:	(408) 266-1660
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	63	CENSUS: 45	DATE:	01/02/2026
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Administrator Kurt Gursu		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Facility is not reporting incidents to CDSS

INVESTIGATION FINDINGS:

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On November 10, 2025 the Department received a complaint alleging Facility is not reporting incidents to CDSS

LPA Manuel Monter interviewed Memory Care Director (MCD) Janice Lacambra. MCD stated whenever there is an incident at the facility, its reported licensing. MCD stated any fall, any injury, any incident is reported to CDSS. MCD stated she isn’t aware of any time an incident occurred at the facility and wasn’t reported to CDSS.

LPA Manuel Monter interviewed staff S1-S8. 8 Out of 8 Staff (S1-S8) stated when an incident occurs at the facility, its reported to licensing. 8 Out of 8 Staff (S1-S8) stated they are not aware of any time an incident occurred at the facility and wasn’t reported to CDSS. Page 1 Out of 2.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 26-AS-20251110131747

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 01/02/2026

NARRATIVE

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On December 5, 2025, LPA Manuel Monter interviewed staff S9-S16. 8 Out of 8 staff (S9-S16) stated they are not aware of any time an incident occurred at the facility and wasn’t reported to CDSS.

On December 5, 2025, LPA Manuel Monter interviewed Administrator (ADM) Kurt Gursu. ADM stated All employees have accesses to instant reporting, which employees report witnessed incident. ADM stated these reports go to Memory care director Janice and or himself to submit. ADM stated these incident reports are electronically reported. ADM stated he is not aware of any incident that occurred and wasn’t reported to CDSS

Based on records reviewed, the facility submitted 6 incident reports for the month of November 2025, 10 incident reports for the month of October and 10 incident reports for the month of September. These incidents reports covered the following but not limited to incidents: witnessed falls, unwitnessed falls, altercation between residents, sickness, and emergency room visits.

The Department made multiple attempts to contact the reporting party to obtain additional information regarding the specific incidents that had not been reported to CDSS. Despite numerous attempts, the Department did not receive a response from the reporting party.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Page 2 Out of 2.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 9 of 9