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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200996
Report Date: 05/19/2025
Date Signed: 05/19/2025 02:18:33 PM

Substantiated


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
10/31/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20231031153334
FACILITY NAME:PRINCESS LODGEFACILITY NUMBER:
435200996
ADMINISTRATOR:MORALES, JAMESFACILITY TYPE:
740
ADDRESS:552 WEST HACIENDA AVENUETELEPHONE:
(408) 379-9331
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:30CENSUS: 17DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Rica Uy & Olivia VelasquezTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Cleaning products are accessible to residents in care
INVESTIGATION FINDINGS:
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On 5/19/2025, LPA Grace Donato conducted an unannounced complaint visit to deliver finidings. LPA met with Manager, Rica Uy & Co Administrator Olivia Velasquez and explained the purpose of the visit.

For the allegation of cleaning products are accessible to residents in care, reporting party (RP) stated that their (facility) cleaning materials are not stored properly.

During the initial visit, LPA Dolores toured the facility and observed that in the Laundry Room #2 was not locked with accessible laundry detergents. The laundry room is right next to residents’ bedrooms. S1 verbalized that the laundry room was not originally locked. S1 showed LPA how to lock the laundry room door, but did not know how to open the laundry room door after.

Therefore, based on observations, the above allegation is determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed and copy of report and appeal rights are provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
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 7
Control Number 26-AS-20231031153334
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: PRINCESS LODGE
FACILITY NUMBER: 435200996
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2025
Section Cited
CCR
87309(a)
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87309 Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
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Violation has since been corrected when the investigation started.
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This was not met as evidenced by: Based on observation, Laundry Room #2 was not locked with accessible laundry detergents, which poses an immediate health, safety or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
10/31/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20231031153334

FACILITY NAME:PRINCESS LODGEFACILITY NUMBER:
435200996
ADMINISTRATOR:MORALES, JAMESFACILITY TYPE:
740
ADDRESS:552 WEST HACIENDA AVENUETELEPHONE:
(408) 379-9331
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:30CENSUS: 17DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Rica Uy & Olivia VelasquezTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility is not reporting incidents which threaten welfare, safety or health of residents within 7 days of occurrence
The facility staff does not meet the needs of the residents
Facility not following their infection control policy
Licensee/ADM is not carrying out his/her responsibilities and authority to carry out the policies of the facility.
INVESTIGATION FINDINGS:
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For the allegation of Facility is not reporting incidents which threaten welfare, safety or health of residents within 7 days of occurrence, RP stated that when there is an outbreak /they are hiding incidents and not reporting, falls causing fracture not being reported and rashes not being reported/documented.

Based on records review, facility reported the covid outbreak to Licensing. There is documentation that facility submitted an incident report through fax on September 5, 2023. There was also a phone call follow up done by LPA Rai asking about the census of the facility. On May 18, 2023, LPA Rai also received a report regarding scabies. On March 13, 2023, an incident of fall was submitted and was followed up by LPA Maruffo.

Regarding the allegation of the facility staff does not meet the needs of the residents, RP stated that they don’t have enough staff to take care of their clients.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20231031153334
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: PRINCESS LODGE
FACILITY NUMBER: 435200996
VISIT DATE: 05/19/2025
NARRATIVE
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During LPA Dolores’ visit, 4 staff were observed to be working. During LPA Donato’s visit there were about 5 staff working, some are with residents in the dining area, some were at the living room watching tv with the residents. LPA also observed that when a resident called for help, a staff was there to attend to the resident.

For the allegation of facility not following their infection control policy, RP stated that COVID protocol/infection control not properly implemented when there is an outbreak.

LPA interviewed staff members. S1 stated that they do have isolation rooms in case there is an outbreak. It's located in between the office and main rooms.There's a separate entrance with ramp. LPA documented the area through photos. Food is left to the staff room in between the isolation room and hallway and is taken by a staff assigned to serve it to residents. Incident reports are also submitted to licensing.

Regarding the allegation of Licensee/ADM is not carrying out his/her responsibilities and authority to carry out the policies of the facility, RP stated that owners of the facility area always out of the country and doesn’t care what’s going on in the facility.

During the interviews, S1 and S2 stated that Administrators Judith and James Morales is here basically every day when they are here in the area.

Based on records review, there are other staff who are qualified administrators also and are there when Licensees are not around.

Although the allegations may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED.

Report is reviewed and copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
10/31/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20231031153334

FACILITY NAME:PRINCESS LODGEFACILITY NUMBER:
435200996
ADMINISTRATOR:MORALES, JAMESFACILITY TYPE:
740
ADDRESS:552 WEST HACIENDA AVENUETELEPHONE:
(408) 379-9331
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:30CENSUS: 17DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Rica Uy & Olivia VelasquezTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff does not have 40 hours of required training
Facility falsifies staff and resident documents
Residents medications are not being administered per physicians order.
The facility is unsanitary.
The facility does not have sufficient lights to ensure the comfort and safety of residents
Residents medications are accessible
Facility has a staff member who is not fingerprinted
Facility has a kitchen in the second floor, which is a fire hazard.
INVESTIGATION FINDINGS:
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For the allegation of staff does not have 40 hours of required training and facility falsifies staff and resident documents.

LPA Donato reviewed documents provided by the facility. New hires from 2023 had documented 40 hours training upon hiring. Facility staff who also have been there since 2002 have documented training upon hiring. There are only 10 hours of initial training because during that time the regulations only state 10 hours of initial training. LPA also reviewed resident files, and all are updated and signed by a physician for the medical assessments, centrally stored medication records matched the medical administration records. The needs and services plans are also discussed and signed by responsible parties.

page 1 of 3
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20231031153334
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: PRINCESS LODGE
FACILITY NUMBER: 435200996
VISIT DATE: 05/19/2025
NARRATIVE
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Regarding the allegations of Residents medications are not being administered per physician’s order and residents’ medications are accessible, Reporting Party (RP) stated that medications are not properly administered/caregivers are giving meds instead of the med-clerk/some residents are hiding medication in their room without proper documentation.

Based on records review, 5 out of 5 resident’s medication administration records (MAR) have accurate logs of when medications are given to residents. It is also noted in the MAR if medications are discontinued. Facility also has an updated Centrally Store Medication & Destruction Records (CSMDR) for the 5 residents.

During the visit of LPA Dolores, it was observed that a medication cart in the dining room which was observed locked. LPA Donato, on the subsequent visit, also observed this medication cart and PRN medications were locked inside a room in one of the offices. LPA Donato also toured random rooms. LPA checked all the closets and cabinets and only saw body lotions and wipes for the residents. There were no medications found in the rooms.

Regarding the allegation that the facility does not have sufficient lights to ensure the comfort and safety of residents and facility is unsanitary, reporting party (RP) stated that The facility is dark not too filthy but there is an unexplainable smell when we toured.

During the initial visit, LPA Dolores toured the facility and observed that the smell of the facility to smell like multiple perfumes and air fresheners. The facility was clean and sanitary with clean floors and surfaces. Resident bedrooms well kept. The beds were made, no random items and objects laying around the floor. The floors observed with no obvious dirt marking and sticky surfaces. Fire exits were free and clear of obstruction. LPA observed the hallways were dim when the lights are off. Hallways and dim spaces contain light switches. LPA observes the areas were well lit once lights were turned on. LPA Donato also visited and observed that the facility is clean and well maintained, there were night lights in the facility hallways. The residents’ rooms are well kept.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20231031153334
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: PRINCESS LODGE
FACILITY NUMBER: 435200996
VISIT DATE: 05/19/2025
NARRATIVE
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For the allegation of facility has a staff member who is not fingerprinted, RP stated that Facility is harboring undocumented employee mostly working at night.

LPA Dolores checked on the staff that works and lives in the facility. All three staff members who resides on the 2nd floor of the facility are all fingerprinted and associated in the facility. The facility has apartments at the back. LPA Donato crosschecked the people living there during the time of complaint and everyone is associated with the facility and fingerprint cleared, one being a non-client adult resident due to the person just residing in the apartments and not working as staff.

For the allegation of Facility has a kitchen in the second floor, which is a fire hazard RP stated that Staff rooms upstairs is filthy and has a kitchen that is dangerous to fire.

LPA Dolores toured the 2nd floor and it was observed that it contained a kitchen. The kitchen did not have a stove. LPA observed a vintage oven connected to the wall. S1 states the oven is not working. S1 opened the oven and LPA observed the oven was filled with storage containers. The kitchen area had 2 refrigerators, a microwave, dining table, and rice cooker. LPA observed a fire extinguisher sitting on the kitchen table.

Based on observations & records review the department has determined that that these allegations are false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is reviewed and copy is provided.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7