435201105-8-18-2025-26-AS-MPAA-DKQ7C5-20250819213209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201105
Report Date: 08/18/2025
Date Signed: 08/18/2025 12:07:11 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
10/25/2024 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20241025151500

FACILITY NAME:	HILLSDALE HOME		FACILITY NUMBER:	435201105
ADMINISTRATOR:	JOHN TANAKA		FACILITY TYPE:	735
ADDRESS:	318 LOS PINOS WAY		TELEPHONE:	(408) 599-9597
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95119
CAPACITY:	6	CENSUS: 3	DATE:	08/18/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator/Licensee John Tanaka		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Facility did not ensure refrigerator is in good repair at all times.
Facilty did not ensure staff obtained a criminal record clearance prior to working, residing or volunteering in a licensed facility.
Facility did not ensure for the resident's personal rights to be free from verbal threat or harm.
Facility did not ensure that food was of good quality because food in the refrigerator exceeded the expiration dates.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced visit to deliver the complaint findings and met with administrator (ADM) John Tanaka and stated the purpose of the visit.

On 10/24/2024 the Department received the complaint with the above allegations.

On 11/02/2024 the Department conducted an initial complaint investigation visit, interviewed 2 Staff (S1 to S2), and 4 Residents (R1 to R4).

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20241025151500

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: HILLSDALE HOME	FACILITY NUMBER: 435201105
	VISIT DATE: 08/18/2025

NARRATIVE

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Facility did not ensure refrigerator is in good repair at all times.
On 11/2/2024 the Department interviewed 4 residents (R1 to R4). 3 Out of 4 residents stated that the facility refrigerator is working and in good repair. 1 Out of 4 residents stated the refrigerator at the garage was not working, however, R1 could not give a specific date and time when the refrigerator was observed not working.

On 11/1/2024 during the initial investigation, LPAs inspected the freezer (located in the garage) and the temperature was measured and recorded at 20 degrees F. 1 Out of 1 staff stated that the refrigerator is for staff to store food and not used to store resident’s food. LPA observed that the refrigerator had a label “staff only.”

On 8/18/2025 LPA Tarin inspected 2 refrigerators and 1 freezer and observed the following: 2 Out of 2 refrigerators/freezers temperatures were measured and recorded (located in the garage and kitchen) at 40F / 0F. 1 Out of 1 freezer (located in garage) temperature was measured and recorded at -10F. Based on observation 2 Out of 2 refrigerator/freezer temperatures measured at 40F / 0F and 1 Out 1 freezer measured at -10F.

LPA Tarin observed 2 out of 2 refrigerators and 1 Out of 1 freezer to be in good repair and working properly during visit.

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SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20241025151500

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: HILLSDALE HOME	FACILITY NUMBER: 435201105
	VISIT DATE: 08/18/2025

NARRATIVE

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Facility did not ensure staff obtained a criminal record clearance prior to working, residing or volunteering in a licensed facility.

On 11/01/2024, S2 was interviewed and stated S3 was employed and living at the facility from March 1, 2024 without obtaining a background clearance and ended his/her employment on 9/24/2024, furthermore S2 stated that during S3's employment he/she prepares meals for residents every Sunday.

Based on interviews of 4 residents (R1 to R4). 4 Out of 4 residents stated and observed S3 at the facility from March 1 2024 to September 24, 2024. 3 Out of 4 resident stated that they observed S3 in the facility but were unable to provide additional information as to what S3 was doing in the facility. R3 stated S3 ‘talks mean’ but did not provide any date or time when this occurred.

Based on document review, S3 did not have a background clearance since S3 started his/her employment or residency at the facility on March 1, 2024. Subsequently, during an annual inspection conducted on 6/26/2024 a citation was issued for S3 for not having a background clearance. On 6/28/2024 the citation was cleared and the Department.

Facility did not ensure for the resident's personal rights to be free from verbal threat or harm.
On 11/1/2024 the Department interviewed 2 Staff (S1 to S2). 1 Out of 2 staff stated he/she heard S3 make a threat toward a resident’s pet. S2 stated that S1 admitted to threatening the resident’s pet. S2 was not able to provide the date and time when the incident happened.

Based on interviews of 4 residents (R1 to R4). 3 Out of 4 residents stated that he/she did not observe S3 verbally threaten or harm residents in care. R3 stated that he/she observed S3 make a threat towards a resident’s pet, but did not provide the date or time this incident occurred.

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SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20241025151500

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: HILLSDALE HOME	FACILITY NUMBER: 435201105
	VISIT DATE: 08/18/2025

NARRATIVE

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Facility did not ensure that food was of good quality because food in the refrigerator exceeded the expiration dates.
Based on interview of 2 staff, 2 Out of 2 Staff stated the facility do not store expired food.

Based on interview of 4 residents (R1 to R4), 3 Out of 4 residents stated that they did not observe and have not been served expired food. 1 Out of 4 residents did not give any information or observation regarding expired food.

LPA Tarin randomly inspected the facility food storage, including but not limited to the refrigerator and food pantry. LPA observed that the facility stores 7 days of non-perishable food, and 2 days of perishable food. LPA observed and noted food stored were not expired and conforms to the requirement of California Code of Regulations (CCR) Title 22 85076, Food Service.

Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation are UNSUBSTANTIATED. An exit interview was conducted with the administrator, John Tanaka and a copy of this report was provided.

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END OF REPORT

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025

LIC9099 (FAS) - (06/04)

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