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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200735
Report Date: 11/22/2021
Date Signed: 11/22/2021 06:18:06 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/24/2021 and conducted by Evaluator Steve Nguyen
COMPLAINT CONTROL NUMBER: 26-AS-20210624145720
FACILITY NAME:HOMESIDE RETREATFACILITY NUMBER:
435200735
ADMINISTRATOR:REBOTON, C. FLOROFACILITY TYPE:
735
ADDRESS:3330 BIEN WAYTELEPHONE:
(408) 531-8640
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 5DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Giselle CorralTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility has pests.
Staff made an inappropriate comment to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Nguyen arrived unannounced to deliver the complaint investigation finding. LPA met with Staff, Giselle Corral, and explained the purpose of the visit.

On 06/24/2021 the Department received a complaint regarding the above allegations.

On 06/29/2021 LPA Steve Nguyen and LPM Jackie Jin, opened the unannounced 10-day Complaint investigation and advised the Administrator, REBOTON, C. FLORO, that the Department would be conducting the investigation.

Between 6/29/2021 and 11/21/2021, the Department: interviewed the Administrator, 2 staff and 4 residents. Records reviewed includes but are not limited to: Plan of Operations, SIR/ documents related to pest issues, and facility's policies in addressing residents’ concerns.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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 2
Control Number 26-AS-20210624145720
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: HOMESIDE RETREAT
FACILITY NUMBER: 435200735
VISIT DATE: 11/22/2021
NARRATIVE
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3 out of 3 staff denied all allegations: all stated that facility took immediate action upon discovery of bed bugs. Process included but not limited to: Vacuuming, cleaning, washing, replacing drawers, mattress with plastic coverings and the use of bed bug heater. All 3 denied any instances of inappropriate comment to any residents.

3 out of 4 clients stated that rooms are clean and no instances of inappropriate comments from staff towards clients. 1 client stated to have been bitten by bed bugs and that at times there were inappropriate comments from staff towards client.

Based on information from interviews conducted 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 allegations are UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22.

This report was reviewed with Staff, Giselle Corral, and a copy of this report provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2