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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200666
Report Date: 01/29/2026
Date Signed: 01/29/2026 04:27:24 PM

Substantiated


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
10/17/2025 and conducted by Evaluator Marcela Yanez
COMPLAINT CONTROL NUMBER: 26-AS-20251017152725
FACILITY NAME:VALDEZ CARE HOMEFACILITY NUMBER:
435200666
ADMINISTRATOR:CARRANZA, HELEN V.FACILITY TYPE:
735
ADDRESS:2565 SUGAR PLUM DRIVETELEPHONE:
(408) 270-2613
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 5DATE:
01/29/2026
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Marilou BancudTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff did not distribute resident's medication as prescribed
Staff did not report incident to appropriate parties
INVESTIGATION FINDINGS:
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On 1/29/26 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint investigation visit to deliver findings. LPA announced the purpose of the visit. LPA met with Marilou Bancud Lead Staff. Administrator was contacted by phone and stated Lead staff can sign on his behalf.

On 10/17/25 the department received a complaint with the above allegations.

During the investigation the department interviewed 3 Staff (S1-S3). S1 stated that Resident (R1) had fallen and had been prescribed a new medication that might cause drowsiness. S1 stated that he/she asked S3 and S3 stated to hold the medication. S1 stated he/she did not give the medication to R1 for 3 days. S3 stated he/she did not instruct S1 not to give medication. The facility is utilizing Centrally stored medication record.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
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 4
Control Number 26-AS-20251017152725
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: VALDEZ CARE HOME
FACILITY NUMBER: 435200666
VISIT DATE: 01/29/2026
NARRATIVE
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LPA conducted an audit of the centrally stored medication record and cross referenced when prescription was dispensed from the start date of medication. Based on audit the medication was not administered for a total of 3 days. S1 confirmed he/she did not administer medication for 3 days.

S2 stated he/she was not aware of the incidents when resident fell on 10/11/25. S2 stated he/she reports incidents to the department when an incident occurs. S2 stated that he/she was not aware of the new medication not being administered to R1. S2 stated that when a resident falls caregivers are instructed to call licensee, and licensee will inform S2 of the fall. S2 stated that residents are observed and checked for any injuries and then will call 911 if warranted. S2 stated the responsible party is informed of incident. Per S1
R1 had a fall 10/11/25 and licensee was informed and S2 stated he/she did not report it to Licensing because he/she was not aware.

The department completed its investigation and determined based on records review, interviews and observations there is preponderance of evidence to prove the alleged violation did occur; therefore, the allegations are substantiated. See both allegations on 9099-D for deficiency cited per the California Code of Regulations, Title 22.


This report was reviewed with Marilou Bancud and a copy of report and appeals rights were provided.
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20251017152725
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: VALDEZ CARE HOME
FACILITY NUMBER: 435200666
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2026
Section Cited
CCR
80075(b)
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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement was not met as evidenced by;
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ADM per phone conversation stated he/she will submit a letter of understanding of the regulation on staff administering medication.
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Based on record review and interview and observation R1 did not receive medication for a total of 3 days from date the medication was dispensed. S1 stated he/she did not administer medication for a total of 3 days. which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 26-AS-20251017152725
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: VALDEZ CARE HOME
FACILITY NUMBER: 435200666
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2026
Section Cited
CCR
80061(a)(b)
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a) Each licensee or applicant shall furnish to the licensing agency reports as...(b)Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day...a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days...This requirement was not met as evidenced by;
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ADM stated per phone conversation he/she will submit a letter of undersanding of regulation
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Based on observation and record review the facility did not comply by not submitting an incident report for R1 fall on 10/11/25 which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4