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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201311
Report Date: 07/29/2024
Date Signed: 07/29/2024 04:12:19 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
07/21/2024 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20240721231301
FACILITY NAME:ROSSMORE A.R.F. HOMEFACILITY NUMBER:
435201311
ADMINISTRATOR:HELEN V. CARRANZAFACILITY TYPE:
735
ADDRESS:2955 ROSSMORE LANETELEPHONE:
(408) 531-9487
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 4DATE:
07/29/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ernie ManaoisTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff leaves the clients unattended while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced initial complaint investigation visit and met with Ernie Manaois, Administrator (ADM). On 07/21/2024, the Department received a complaint with the above allegation.

On 07/29/2024, LPA Marrufo conducted a telephone interview with a witness who stated to have observed no staff at the facility on 07/07/2024 and 07/14/2024 from 10:30 AM to 12:20 PM on both days. On 07/29/2024, LPA Marrufo interviewed staff S1, who stated that there have been times when S1 leaves the facility on Sundays to attend church for one hour and there are no staff at the facility to supervise the residents. On 07/29/2024, ADM stated during interview that on 07/07/2024, the facility was left without a staff to supervise the residents for 30 minutes. LPA Marrufo interviewed residents R1-R3. R1 stated that staff ask R1 to cover for staff to supervise the other residents while staff go to church. R2 and R3 stated to have not observed a time when staff leave the residents unattended while in care. See LIC9099-C for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
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 3
Control Number 26-AS-20240721231301
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: ROSSMORE A.R.F. HOME
FACILITY NUMBER: 435201311
VISIT DATE: 07/29/2024
NARRATIVE
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Based on interviews with staff, residents, and a witness, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated.

ADM Ernie Manaois emailed a copy of the LIC500 Personnel Report to LPA Marrufo during visit.

During visit, LPA Marrufo informed ADM and S1 that the facility is licensed to provide care and supervision to residents 24 hours a day every day.

See LIC9099-D for deficiencies cited per the California Code of Regulations Title 22.

This report was reviewed with ADM Ernie Manaois and a copy of this report and appeal rights were provided.



Page 2 of 2.

END REPORT
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20240721231301
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: ROSSMORE A.R.F. HOME
FACILITY NUMBER: 435201311
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2024
Section Cited
CCR
80078(a)
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80078 (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: Licensee did not ensure that a staff provided coverage for S1 when S1 left the facility with no staff to provide supervision
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Licensee agrees to submit a Plan of Correction to CCL by POC date explaining how the Licensee shall ensure that there is staff present at the facility to supervise the residents at all times, including when staff leave the facility to attend religious services on Sundays.
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of residents, which poses an immediate safety risk to residents 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.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3