435200608-10-26-2022-26-AS-SYIP-CKYRAB-20221108115053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200608
Report Date: 10/26/2022
Date Signed: 10/26/2022 04:57:23 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
05/04/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210504094222

FACILITY NAME:	MAYFLOWER CARE HOME		FACILITY NUMBER:	435200608
ADMINISTRATOR:	ESLAVA, ISABEL M.		FACILITY TYPE:	740
ADDRESS:	668 APACHE COURT		TELEPHONE:	(408) 972-1999
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 4	DATE:	10/26/2022
		UNANNOUNCED	TIME BEGAN:	03:08 PM
MET WITH:	Isabel Eslava		TIME COMPLETED:	05:03 PM

ALLEGATION(S):

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Facility Administrator is financially abusing resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced visit to deliver the complaint investigation findings on the above allegation. LPA met with facility Administrator Isabel Eslava (Admin).

The Department interviewed the alleged victim (R1) of financial abuse and reviewed his/her financial records. During interview (R1) was able to recall details regarding the alleged suspicious charges to his/her credit card. R1 recalled suspicious expenditures were for the actual purpose of purchasing personal items. R1 was accompanied by facility staff during these excursions. R1 asserted that facility staff did not assist him/her with purchases and that he/she maintains custody of his/her debit card and makes his/her own purchases. Review of R1's physician's report indicate that he/she is able to make his/her own financial decisions.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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-20210504094222

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: MAYFLOWER CARE HOME	FACILITY NUMBER: 435200608
	VISIT DATE: 10/26/2022

NARRATIVE

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During review of R1's bank statements and financial records, no other charges to resident's account were noted to be suspicious in nature. In review of audited bank statements of resident and facility accounts, no deposits of residents' withdrawn funds were noted in the facility's statements.

In interviews with residents' responsible parties, responsible parties noted that they pay board and care directly to licensee via checks or online payments. Although the licensee did raise some residents’ B&C rate – responsible parties were given requisite advance notice. Responsible parties indicated that no one sends monies to the facility, for resident’s personal and incidental expenditures. All interviewees indicated the licensee does not handle resident’s monies.

Based on information from interviews conducted with staff and residents, 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 allegation is UNSUBSTANTIATED.

No deficiencies cited under Title 22. Report was reviewed with and signed by Administrator Isabel Eslava and a copy was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC9099 (FAS) - (06/04)

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