435201319-5-20-2026-26-AS-RMAO-DURJVD-20260605072258

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201319
Report Date: 05/20/2026
Date Signed: 05/20/2026 04:18:08 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
01/28/2026 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20260128100937

FACILITY NAME:	CAPRI HOME		FACILITY NUMBER:	435201319
ADMINISTRATOR:	GANIYU AJANI		FACILITY TYPE:	735
ADDRESS:	1849 ST. ANDREWS PLACE		TELEPHONE:	(408) 254-9452
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95132
CAPACITY:	6	CENSUS: 5	DATE:	05/20/2026
		UNANNOUNCED	TIME BEGAN:	03:39 PM
MET WITH:	Jerry Carta		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Due to staff neglect resident developed pneumonia while in care.
Facility did not seek medical attention for resident in a timely manner.

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 House Manager (HM) Jerry Carta.

On 01/28/2026, The Department received a complaint with the above two allegations.

On 02/03/2026, the Department conducted an initial investigation visit.

LPA interviewed ADM and two staff.

LPA requested resident R1's physician report, appraisal needs and service, and Individual Program Plan.

Continue on LIC9099-C. Page 1 of 4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

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 4

Control Number 26-AS-20260128100937

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: CAPRI HOME	FACILITY NUMBER: 435201319
	VISIT DATE: 05/20/2026

NARRATIVE

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Due to staff neglect resident developed pneumonia while in care:
Facility did not seek medical attention for resident in a timely manner:
On 02/03/2026, LPA interviewed Administrator (ADM) Ganiyu Ajani. ADM stated on 01/25/2026 morning, R1's family members (FM1, FM2) came to the facility to visit R1. ADM stated R1 was checked temperature on 01/25/2026 morning, and the temperature was 97.8 degree F. ADM stated R1 finished breakfast and shower in the morning on 01/25/2026 before FM1 and FM2 arrived at the facility. ADM stated R1's families found R1 was weak and sleepy during their visit. ADM stated he/she explained to R1's families that R1 does not sleep whole night, and kept waking up and walking in the facility. ADM stated he/she explained to FM1 and FM2 that facility staff checked R1's temperature and it was 97.8 degree F which is within the normal range. ADM stated FM1 and FM2 discussed R1's condition on the phone with R1's another family member (FM3). ADM stated FM3 asked him/her to send R1 to hospital. ADM stated he/she had two facility staff sent R1 to hospital on 01/25/2026 around noon time and FM1 and FM2 met R1 at the hospital.

LPA interviewed staff S1. S1 stated on 01/25/2026, FM1 and FM2 visited R1. FM1 and FM2 found R1 was weak, sleepy, and was breathing wheezily. S1 stated he/she took R1's temperature on 01/25/2026 morning and it was 97.8 degree F which is within normal range. S1 stated R1 usually does not sleep whole night and always wakes up during the night. S1 stated R1 is always sleepy at day time. S1 stated R1's families requested to send R1 to hospital. S1 stated two facility staff sent R1 to hospital on 01/25/2026 at noon time.

LPA interviewed staff S2. S2 stated on 01/25/2026, he/she came to work before 12:00PM. S2 stated R1's families requested to send R1 to hospital. S2 stated he/she asked R1's family why and R1's families stated R1 was weak and sleepy. S2 stated he/she explained to R1's families that R1 does not sleep much at night and is always sleepy in the morning. S2 stated R1's families insisted to send R1 to hospital. S2 stated he/she and another staff sent R1 to hospital on 01/25/2026 around noon time..

On 03/26/2026, LPA interviewed FM1. FM1 stated on 01/25/2026 morning, FM2 asked him/her to go with FM2 to visit R1. FM1 stated he/she found R1 was very weak and sleepy which was much different with R1's usual. FM1 stated he/she gave R1's favorite food but R1 did not want it. FM1 stated he/she gave R1 a cup of water, and R1 vomited out. FM1 stated R1 was unable to stand up on 01/25/2026 morning and he/she had to put R1 to rest on bed. FM1 stated R1 was breathing with wheeze.

Continue on LIC9099-C. Page 2 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20260128100937

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: CAPRI HOME	FACILITY NUMBER: 435201319
	VISIT DATE: 05/20/2026

NARRATIVE

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FM1 stated he/she discussed R1's condition with FM3 on the phone and decided to send R1 to hospital. FM1 stated R1 was diagnosed with pneumonia later in the hospital. R1 was admitted in the hospital.

LPA interviewed FM3. FM3 stated on 01/25/2026 morning, FM1 and FM2 visited R1 and found R1 was sick. FM3 stated he/she used FaceTime to talk with FM1 and FM2, and looked at R1. FM3 stated he/she found R1 was sick and asked the facility to send R1 to hospital. FM3 stated R1 was admitted in the hospital and was diagnosed with pneumonia.

On 04/18/2026, LPA contacted FM3 to request R1's medical document in addition to R1's discharge document that specifies R1 was diagnosed pneumonia on 01/25/2026 at the hospital.

On 04/24/2026, LPA interviewed ADM. ADM stated on 01/25/2026, R1 did not cough, R1 was not out of breath, R1 did not breathe wheezily, and did not have fever. ADM stated the facility staff measured R1's temperature before and after R1's families' arrival of the facility and both times were 97.8 degree F which is within the normal range. ADM stated on 01/25/2026 morning staff helped R1 for shower before the arrival of R1's families and R1 was normal. ADM stated on 01/25/2026 morning R1 finished all of his/her breakfast before the arrival's R1's families. ADM stated R1 was able to stand up and to walk on 01/25/2026 morning before the arrival of R1's families.

On the same day, LPA interviewed staff S1. S1 stated on 01/25/2026 mornings, he/she took R1's temperature before and after the arrival of R1's families and both were 97.8 degree F which is within the normal range. S1 stated on 01/25/2026 morning, R1 did not cough, was able to stand up, R1 sat on the couch but did not rest on the bed, R1 finished the shower in the morning, and ate all his/her breakfast.

On the same day, LPA interviewed staff S2. S2 stated on 01/25/2026 morning, R1 was able to stand up, R1 finished the shower, did not cough, did not have fever, finished all of his/her breakfast, and did not breathe wheezily. S2 stated he/she held R1's arm to walk in the facility for exercise on 01/25/2026 morning. S2 stated he/she was with R1 sitting on the chair on 01/25/2026 morning before R1's families arrived at the facility.
Continue on LIC9099-C. Page 3 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20260128100937

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: CAPRI HOME	FACILITY NUMBER: 435201319
	VISIT DATE: 05/20/2026

NARRATIVE

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On 04/29/2026, LPA left voicemail to FM3 to request to send R1's medical document with R1's diagnosis of pneumonia. But LPA did not receive response.

Based on the review of R1's discharge document, R1 was admitted in the hospital from 01/25/2026 to 03/04/2026. R1's discharge document does not specify R1 was diagnosed with pneumonia.

On 05/20/2026, LPA did not receive additional R1's medical document with the diagnosis of pneumonia on 01/25/2026 at the hospital.

Based on the interview and records reviewed, there is no evidence that the facility staff's neglect leading R1 developing pneumonia.

The department has investigated the above allegation. Based on records reviewed, 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 compliant investigation visit. Exit interview conducted with HM. A copy of this report was provided to HM.

Page 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 4