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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200680
Report Date: 04/02/2024
Date Signed: 04/02/2024 11:29:12 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
10/21/2021 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20211021110007
FACILITY NAME:MONTE BELLO ADULT CARE HOMEFACILITY NUMBER:
435200680
ADMINISTRATOR:DULCE ROSE CERAFACILITY TYPE:
735
ADDRESS:998 A-B MONTE BELLO DRTELEPHONE:
(408) 847-9999
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:6CENSUS: 6DATE:
04/02/2024
UNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:Audrey SalvadorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is under staffed
Licensee is falsifying facility records
Facility is not providing residents nutrional meals
Facility staff are not adequately trained/underqualified
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 4/2/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint inspection. LPA met with Administrator Audrey Salvador 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 10/21/2021, the Department received a report alleging that facility is understaffed; licensee is falsifying facility records; facility is not providing residents nutritional meals; and facility staff are not adequately trained/underqualified.

The Department conducted interviews and record reviews. Based on the information available, it was unable to prove whether the facility was understaffed; the licensee was falsifying facility records; the facility was not providing residents with nutritious meals; and the facility staff were not adequately trained/underqualified.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are 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: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
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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