435200918-7-3-2024-26-AS-RMAO-D7323M-20240710170232

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200918
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:21:14 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
03/29/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20230329163448

FACILITY NAME:	EVCO CARE		FACILITY NUMBER:	435200918
ADMINISTRATOR:	MICHELLE BAYQUEN		FACILITY TYPE:	740
ADDRESS:	3274 EVCO COURT		TELEPHONE:	(408) 937-1625
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	6	CENSUS: 3	DATE:	07/03/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Thelma Blanchard		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff did not supervise residents during altercation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with licensee Thelma Blanchard (LS).

On 03/29/2023, the Department received a complaint that the facility staff did not supervise residents during alteration.

On 04/05/2023, the Department conducted an initial investigation visit.

LPA interviewed interviewed 1 staff and 3 residents.

LPA requested resident's physician report and appraisal/needs and service plan.

Continue on LIC9099-C. page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

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-20230329163448

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: EVCO CARE	FACILITY NUMBER: 435200918
	VISIT DATE: 07/03/2024

NARRATIVE

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On 04/05/2023, LPA interviewed licensee Thelma Blanchard (LS). LS stated he/she was on site when the incident occurred. LS stated there was no alteration, no fighting, and no injury for the incident. LS stated residents R2 and R3 were standing and talking in the kitchen area while resident R1 was walking to refrigerator to get drinks, and R1 elbowed R2 out of the way. LS stated R2 did not react to R1. LS stated R2 did not get hurt and did not complain any pain. LS stated he/she reported the incident to R1's case manager by phone.

LPA interviewed resident R1. R1 was unable to describe what happened for the incident.

LPA interviewed resident R2. R2 stated he/she did not react to R1's behavior. R2 stated he/she did not get hurt and did not feel pain.

LPA interviewed resident R4 who stated he/she heard there was an incident around 2 weeks ago, but he/she was not in the facility and did not know the detail.

LPA observed R2 had no injury, redness or bruise on R2's body.

Based on the interviews, a staff was on site supervising the residents. There was no alteration or fighting among residents at that time of the incident. There is no evidence to indicate the facility staff did not supervise residents during the incident.

Based on investigation, observations, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No citations noted at today’s complaint investigation visit. Exit interview was conducted with LS. This report was provided to LS.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2