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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201493
Report Date: 07/24/2020
Date Signed: 07/24/2020 11:02:13 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/19/2020 and conducted by Evaluator Jackie Jin
COMPLAINT CONTROL NUMBER: 26-AS-20200519144817
FACILITY NAME:A HEAVENLY CARE HOMEFACILITY NUMBER:
435201493
ADMINISTRATOR:FONTANILLA, DIANAFACILITY TYPE:
740
ADDRESS:259 CHECKERS DRIVETELEPHONE:
(408) 926-3285
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY:6CENSUS: 1DATE:
07/24/2020
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Diana Fontanilla, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility is not allowing resident to receive calls from family member
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jackie Jin and Ryker Heberle conducted a tele-visit due to COVID-19 health pandemic to deliver the finding to the above allegation. LPA met with Diana Fontanilla, Administrator.

Between 05/27/2020-06/08/2020 the Administrator and a staff member was interviewed. 2 out of 2 denied the facility not allowing residents to receive calls from their family members. Both stated that when a resident receives a call at the facility, staff will let the resident know and bring the phone to the resident if they want to take the call.

On 06/08/2020 two residents were interviewed. 1 out of 2 residents stated that they can receive calls from their family. One resident was not able to answer due to cognitive disorder.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020
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 2
Control Number 26-AS-20200519144817
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: A HEAVENLY CARE HOME
FACILITY NUMBER: 435201493
VISIT DATE: 07/24/2020
NARRATIVE
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On 06/16/2020 a family member was interviewed. The family member stated that the resident can receive calls from their family. The family member does not have any direct knowledge of a time the resident was not able to receive any calls from their family. The family member also does not have any direct knowledge if the facility restricts any family member from calling.

This Department has investigated the above allegation, and based on interviews and record reviews, the Department has determined that the allegation was Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

This report was reviewed with Diana Fontanilla, Administrator and a copy of this report will be emailed to Diana Fontanilla, Administrator on 07/24/2020 for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2