435200696-7-18-2023-26-AS-KHOS-CURLZ4-20230816091119

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200696
Report Date: 07/18/2023
Date Signed: 07/18/2023 06:03:52 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
03/23/2020 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20200323154048

FACILITY NAME:	MARIAN HALL		FACILITY NUMBER:	435200696
ADMINISTRATOR:	ADORAIM VILLANUEVA		FACILITY TYPE:	735
ADDRESS:	443 SOUTH 11TH STREET		TELEPHONE:	(408) 279-9892
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	34	CENSUS: 30	DATE:	07/18/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Margie Villanueva		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Staff caused injury to resident
Resident's are not provided with an adequate amount of food

INVESTIGATION FINDINGS:

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On 03/23/2020, the Department received a complaint with the above allegations. On 04/02/2020, LPA Marrufo conducted an initial complaint investigation visit.

The Department obtained and reviewed resident R1’s resident record wh8ich contains a hospital discharge document stating R1 was seen at the hospital on 03/21/2020 for arm pain and a scaphoid fracture.

On 03/30/2020, the facility submitted an Unusual Incident/Injury Report. The report stated that on 03/21/2020, staff S1 called the administrator (ADM) at 4:40 PM and reported that R1 spat in S1’s face after S1 told R1 to wait to receive medications. S1 reported to ADM over telephone that S1 told R1 that R1 could be written up for spitting in S1’s face. S1 reported that R1 became enraged and began hitting S1. S1 told ADM that R1 called the police.

See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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 5

Control Number 26-AS-20200323154048

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: MARIAN HALL	FACILITY NUMBER: 435200696
	VISIT DATE: 07/18/2023

NARRATIVE

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On 09/22/2021, Resident R1 stated staff S1 slapped R1’s hand, resulting in bruising, and spit at R1. R1 stated to have had to go to the hospital for the bruise. R1 stated that R1 requested medications from S1 and R1 was late taking the medications. R1 stated S1 was mad at R1 for being late and slapped R1’s hands.

On 09/22/2021, Staff S1 stated R1 became agitated during medication pass and spat in S1’s face. S1 stated to have told R1 that R1 would be written up for spitting in R1’s face. S1 stated R1 began hitting R1 and S1 put up S1’s arms to block R1’s hits but did not strike back at R1.

On 07/14/2023, LPA Marrufo interviewed two residents, R2 and R3, who stated to have observed R1 spit at S1 and hit S1. R2 and R3 stated to have observed S1 put up S1’s arms to block from R1’s hits but did not observe S1 hit R1 back.

On 07/18/2023, R1 stated to have hit S1 because S1 said “bad words” to R1. R1 stated S1 put S1’s arms up in an “X” and R1 hit S1 on S1’s forearms. R1 stated R1’s wrists hurt when R1 hit S1. R1 stated to have not spat on S1. R1 stated S1 hit R1 first.

On 09/22/2021, R1 stated that R1 requested an apple from S1, but S1 refused R1’s request for an apple and told R1 that R1 cannot have an apple because S1 was mad at R1.

On 07/18/2023, S1 stated during interview to not recall if S1 ever denied R1’s request for an apple or a second serving of a meal.

On 09/22/2021, LPA Marrufo interviewed 9 residents and 3 staff. 4 out of 9 interviewed residents stated the facility does not always provide second servings of meals when a resident requests. 6 out of 9 residents stated the facility does always provide residents with a second serving of a meal when a resident requests.

Page 2 of 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20200323154048

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: MARIAN HALL	FACILITY NUMBER: 435200696
	VISIT DATE: 07/18/2023

NARRATIVE

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9 out of 9 residents and 3 out of 3 interviewed staff stated the facility serves adequate portions of food and provides second servings of food to residents upon request.

LPA Marrufo observed facility lunch meal service and took photographs of meals, which included gravy over chicken and rice, vegetables, and a brownie.

Based on information from interviews conducted with staff and residents, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

Although there is record that R1 sustained a fracture, it cannot be determined if the fracture was caused by S1 hitting R1. Due to conflicting statements from R1 and S1 regarding whether or not S1 denied R1 an apple or second serving of food, it cannot be determined if S1 denied R1 any food. Additionally, interviewed residents did not provide specific examples or dates of times when they were denied a second serving of food.

No Deficiencies cited under California Code of Regulations Title 22.

This report was reviewed with Margie Villanueva and a copy of the report was provided.

Page 3 of 3. END REPORT.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
03/23/2020 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20200323154048

FACILITY NAME:	MARIAN HALL		FACILITY NUMBER:	435200696
ADMINISTRATOR:	ADORAIM VILLANUEVA		FACILITY TYPE:	735
ADDRESS:	443 SOUTH 11TH STREET		TELEPHONE:	(408) 279-9892
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	34	CENSUS: 30	DATE:	07/18/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Margie Villanueva		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Staff is verbally abusive to residents
Staff interacted with resident in an inappropriate manner

INVESTIGATION FINDINGS:

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On 09/22/2021, LPA Marrufo interviewed 9 residents. 4 out of 9 interviewed residents stated S1 is verbally abusive to residents. S1 and S2 stated that S1 uses curse words in front of residents but does not curse at residents.

Based on interviews with residents and staff, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegations are substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Margie Villanueva and a copy of the report and appeal rights were provided.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20200323154048

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: MARIAN HALL	FACILITY NUMBER: 435200696
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/19/2023 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	80072(a)(1) Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.	1 2 3 4 5 6 7	Licensee agrees to submit a plan to CCL by POC date to train facility staff in personal rights of residents, including not threatening residents and not using foul language at residents or around residents.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: 4 out of 9 interviewed residents stated S1 is verbally abusive to residents. S1 and S2 stated that S1 uses curse words in front of residents but does not curse at residents, which poses an immediate safety risk to residents in care.	8 9 10 11 12 13 14	Licensee shall submit copies of training records to CCL once trainings are complete. The training records should include names of staff trained, training topic, and name and qualifications of trainer.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5