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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200696
Report Date: 07/18/2023
Date Signed: 07/18/2023 05:56:17 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
08/10/2021 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20210810164237
FACILITY NAME:MARIAN HALLFACILITY NUMBER:
435200696
ADMINISTRATOR:ADORAIM VILLANUEVAFACILITY TYPE:
735
ADDRESS:443 SOUTH 11TH STREETTELEPHONE:
(408) 279-9892
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:34CENSUS: 30DATE:
07/18/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Margie VillanuevaTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Client sustained injury while in care
Staff handles client in rough manner
INVESTIGATION FINDINGS:
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On 08/10/2021, the Department received a complaint with the above allegations. On 08/11/2021, LPA Marrufo conducted an initial complaint visit and conducted additional visits on 09/22/2021 and 07/14/2023.

A witness stated to have observed R1 on 08/07/2021 with a scratch on R1’s arm. The witness stated R1 stated that staff S1 pulled R1’s arm to get R1 to get out of bed in the morning.

On 01/10/2021, the facility submitted an incident report stating R1 had an unwitnessed fall that same day. The fall resulted in R1 sustaining a laceration above R1’s left eyebrow. R1 stated to have suddenly felt dizzy and weak while going to the bathroom.

See LIC9099-C for more information. Page 1 of 2.
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 4
Control Number 26-AS-20210810164237
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 has flipped R1’s mattress while R1 was on the mattress, resulting in R1 falling onto the floor. R1 states that S1 has done this multiple times. R1 states S1 flips R1’s mattress to get R1 to take R1’s medications in the morning.

On 07/14/2023, S1 denied ever flipping R1’s mattress while R1 is on the mattress.

On 07/14/2023, R2 stated during interview to have heard R1 fall on to the floor but did not observe S1 in the room with R1.

On 07/18/2023, LPA Marrufo interviewed R1 and S1. R1 stated to have sustained a hand injury that resulted from S1 flipping R1 from R1’s mattress. S1 denied ever flipping R1 from R1’s mattress or pulling on R1’s arm. S1 stated to only ever go upstairs to the resident rooms to conduct nightly room checks.

Based on information from inter,views conducted with staff, 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.

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 2 of 2. 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: 4 of 4
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
08/10/2021 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20210810164237

FACILITY NAME:MARIAN HALLFACILITY NUMBER:
435200696
ADMINISTRATOR:ADORAIM VILLANUEVAFACILITY TYPE:
735
ADDRESS:443 SOUTH 11TH STREETTELEPHONE:
(408) 279-9892
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:34CENSUS: 30DATE:
07/18/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Margie VillanuevaTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff does not treat client with dignity
INVESTIGATION FINDINGS:
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On 09/22/2021, LPA Marrufo interviewed 9 residents as part of another complaint investigation. 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 violation did occur. Therefore, the allegation is substantiated.

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

The facility was issued repeated citations for violations of the same personal rights violation.

This report was reviewed with Margie Villanueva and a copy of the report was 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: 2 of 4
Control Number 26-AS-20210810164237
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)
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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. This requirement was not met as evidenced
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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.
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 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.
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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.
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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: 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: 3 of 4