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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201229
Report Date: 08/22/2025
Date Signed: 08/22/2025 10:12:02 AM

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
07/10/2025 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20250710151220
FACILITY NAME:LOVELY CARE HOMEFACILITY NUMBER:
435201229
ADMINISTRATOR:ELIZA DAQUIOAGFACILITY TYPE:
740
ADDRESS:3640 HEATHCOT COURTTELEPHONE:
(408) 531-9515
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 5DATE:
08/22/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Eliza DaquioagTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff restrained resident
Facility is not meeting the hygiene needs of residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Eliza Daquioag.

Facility is not meeting the hygiene needs of residents in care

On July 10, 2025, the Department received a complaint alleging Facility is not meeting the hygiene needs of residents in care. It has been alleged that resident R1 was observed with multiple diapers.

On July 11, 2025, LPA interviewed Witness W1 and W2. Both witnesses interviewed stated they have observed resident R1 wearing multiple diapers at the same time, on at least 5 different occasions. W1 and W2 stated they were told by the ADM to use multiple diapers on resident R1.
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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
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 6
Control Number 26-AS-20250710151220
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: LOVELY CARE HOME
FACILITY NUMBER: 435201229
VISIT DATE: 08/22/2025
NARRATIVE
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On July 15, 2025, LPA Monter interviewed residents R1-R3. All residents interviewed were unable to respond to questions about complaint allegations due to their neurocognitive disorders.

On July 15 & 24 and August 13, 2025, LPA Monter interviewed Staff S1 and S2. Both admitted they were using multiple diapers on R1, due to R1’s urination, which soils his/her bed and the resident him/herself. S1 stated if residents R1 or R2 get wet at night, they will use 3-4 diapers. S2 stated only R1 has multiple diapers at night. Both staff interviewed acknowledged there wasn’t a difference between R1 soiling him/herself at night or during waking hours.

On July 15 & 24 and August 13, 2025 LPA interviewed ADM. ADM admitted staff place double diapers on R1 at night. ADM stated Only R1 has 2 diapers, because he/she has heavy urination. LPA asked ADM if there is a discrepancy with R1 when he/she soils him/herself in the morning, evening or night. ADM acknowledged that there wasn’t a difference. ADM stated R1 has two diapers at night because at night is easier to take it off and change him/her when he/she has 2 diapers. ADM stated she did instruct her staff to put 2 diapers on R1 at night.

Based on a review of R1's Appraisal / Needs and Services Plan (ANS), dated May 28, 2025, R1 has episodes of yelling, screaming and hitting staff. Furthermore, the ANS states R1 needs 2 people during care. The ANS does not outline a specific bowel and bladder management plan for resident R1.

Based on interviews and documents review the preponderance of evidence has been met therefore the above allegations is found to be SUBSTANTIATED.

Staff restrained resident

On July 10, 2025, the Department received a complaint alleging Staff restrained resident. It has been alleged that R1 was observed lying in bed with both of his/her legs tied together with a bed sheet.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20250710151220
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: LOVELY CARE HOME
FACILITY NUMBER: 435201229
VISIT DATE: 08/22/2025
NARRATIVE
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On July 11, 2025, LPA interviewed Witness W1 and W2. Both witness interviewed stated on July 7, 2025, around 9am both W1 and W2 entered the facility and met with the facility administrator. W1 and W2 headed towards R1’s bedroom and observed resident R1 had his/her feet tied together with a bedsheet. W1 stated he/she asked ADM why R1 feet were tied. Both witnesses stated the ADM had told them, R1 was tied because R1 was being combative when he/she was being changed.

On July 15, 2025, LPA Monter interviewed residents R1-R3. All residents interviewed were unable communicate or respond to interview questions due to their neurocognitive disorder.

On July 15 & 24 and August 13, 2025, LPA Monter interviewed Staff S1. S1 stated on July 7, 2025, the ADM and S2 called him/her for assistance. S1 stated he/she went to R1’s room and helped by holding R1’s hands and holding them close to R1’s chest, while ADM cleaned R1. S1 stated R1 was tied in a manner that was not tight, but closed off enough to keep R1 from kicking his/her feet. S1 stated ADM initiated tying R1’s feet. S1 stated after R1 was tied, two hospice care givers arrived at the care home. S1 stated the hospice care givers arrived either a few minutes or half an hour after R1’s diaper was changed.

On July 15 & 24 and August 13, 2025, LPA Monter interviewed staff S2. S2 stated that morning, R1 was yelling and found R1 had a large bowel movement (BM). S2 stated staff attempted to change R1 but he/she was combative. S2 stated that R1 was mostly kicking and moving his/her arms. S2 stated he/she and the ADM were the ones who did the tying. S2 stated R1 was tied with the bedsheet around R1’s ankles area. S2 stated after R1 was changed, 5-10 minutes later, two staff from redwood hospice came and saw that R1 was tied. S2 stated they forgot to remove the tied bed sheet.

On July 15 & 24 and August 13, 2025, LPA Monter interviewed ADM. ADM stated on July 7, 2025 , around 7:30-8:30am R1 woke up, yelling. ADM stated she saw R1’s had a defecated so much that it leaked out of the diaper. ADM asked S2 for assistance, but R1 was kicking and swinging his/her arms. ADM stated because R1 was being combative, and she decided to tie R1, to get R1 clean and to minimize R1’s from hitting and swinging his arms or hurting himself or the staff. ADM stated R1 was tied slightly above the ankle area. ADM described the tying as not tight, but closed off enough to keep R1 from kicking while he/she is being changed. ADM stated R1 was tied around 8-9am. ADM stated after they assisted R1, the care givers from redwood hospice arrived 15-20 minutes after, and that’s when they saw R1 tied. Page 3 Out of 4.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20250710151220
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: LOVELY CARE HOME
FACILITY NUMBER: 435201229
VISIT DATE: 08/22/2025
NARRATIVE
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Staff S1, S2 and ADM stated that was the only time resident R1 was tied. S1, S2 and ADM acknowledged that R1 has had this combative behavior since move in. S1, S2 and ADM acknowledged that there wasn’t a discrepancy when R1 soiled him/herself in the morning, evening or night.

Based on a review of R1's Appraisal / Needs and Services Plan (ANS), dated May 28, 2025 , R1 has episodes of yelling, screaming and hitting staff. Furthermore, the ANS states R1 needs 2 people during care. The ANS does not detail how the facility will change resident R1 when he/she is being combative.

Based on interviews conducted, Witness observed resident R1’s feet were tied on July 7, 2025. Interviews conducted with facility staff confirmed that on July 7, 2025, R1’s feet were tied, and his/her personal rights were violated. Staff interviewed, stated they tied R1 because of his/her combative behavior when he/she is being changed. Facility staff confirmed R1 has had this combative behavior since move in and R1’s ANS does not detail how the facility will change R1 when he/she is being combative.

Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Administrator Eliza Daquioag. A copy of the report was provided. Appeal rights were provided.

Page 4 Out of 4. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20250710151220
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: LOVELY CARE HOME
FACILITY NUMBER: 435201229
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2025
Section Cited
HSC
1569.50(a)(3)
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1569.50 Denial, suspension or revocation of license; ...exclusion from licensee without right to petition for reinstatement (a)(3) Conduct that is inimical to the health, morals, welfare, or safety ... from the facility or the people of the State of California. This requirement was not met as evidenced by;
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ADM stated she will conduct a personal rights training with her staff. ADM stated she will send documentation of the training with the following information: who participated, who conducted the training, duration of the training, what materials were used.
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Based on interviews conducted, and evidenced reviewed, staff S1, S2 and ADM admitted that resident R1 feet were tied because he/she was being combative when he/she was being changed. This poses an immediate threat to residents health, safety and personal rights.
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ADM stated she will send the plan of corrections to LPA by POC date, August 23, 2025.
Type A
08/23/2025
Section Cited
CCR
87405(d)(2)
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87405 Administrator - Qualifications and Duties (d) (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
This requirement was not met as evidenced by;
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ADM stated she will also send a letter of understanding regarding the regulation and her duties and responsibilities as administrator, which includes respecting residents personal rights not be tied or restrained.
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Based on interviews conducted, ADM admitted to tying R1’s feet, due to R1 being combative when he/she is being changed and the deficiencies cited during this complaint investigation. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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ADM stated she will send the plan of corrections to LPA by POC date, August 23, 2025.
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: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20250710151220
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: LOVELY CARE HOME
FACILITY NUMBER: 435201229
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2025
Section Cited
CCR
87463(a)
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87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, … shall be updated in writing as frequently as necessary … keep the appraisal accurate…
This requirement was not met as evidenced by;
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ADM stated she will develop an updated care plan, to address R1's combative behavior when he/she is being changed, without restraining or tying. ADM stated the updated care plan will also detail R1's updated incontinence plan.
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Based on records reviewed, resident R1’s ANS does not address R1’s combative behavior when he/she is being changed. The ANS also does not detail R1’s incontinence plan. This poses a potential Health, Safety, or Personal Rights risk to persons in care.
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ADM stated she will send the updated care plan to LPA by POC date, August 29, 2025.
Type B
08/29/2025
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by:
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ADM stated she will conduct a training regarding reporting requirement. ADM stated she will submit documentation this training took place by POC date, August 29, 2025.
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Based on interviews conducted, facility staff admitted that R1 was tied and they should have reported it. Based on records reviewed, the facility did not submit an incident report for the incident where R1 was tied. This poses a potential Health, Safety, or Personal Rights risk to persons in care.
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ADM stated she will send a letter of understanding regarding the regulation, and the importance of reporting any incident which threatens the welfare, safety or health of any resident. ADM stated she will send the plan of correction by POC date, August 29, 2025.
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: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6