435201493-3-14-2025-26-AS-KHOS-DEXPSZ-20250320113511

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201493
Report Date: 03/14/2025
Date Signed: 03/14/2025 04:27:22 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
01/28/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20250128124742

FACILITY NAME:	A HEAVENLY CARE HOME		FACILITY NUMBER:	435201493
ADMINISTRATOR:	FONTANILLA, DIANA		FACILITY TYPE:	740
ADDRESS:	259 CHECKERS DRIVE		TELEPHONE:	(408) 926-3285
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95116
CAPACITY:	6	CENSUS: 3	DATE:	03/14/2025
		UNANNOUNCED	TIME BEGAN:	04:05 PM
MET WITH:	Administrator Diana Fontanilla		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff pushed a resident in care
Staff are not providing adequate amounts of food to meet the nutrition needs of residents in care
Staff entered residents bedroom without knocking

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Monter and Marcella Tarin conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Administrator Diana Fontanilla

On January 28, 2025, the Department received a complaint alleging Staff pushed a resident in care. It has been alleged that staff S1 pushed resident R2.

On January 30 & 31, 2025, LPA Monter interviewed residents R1-R5. Resident R1 stated staff S1 pushes R1 onto his/her bed. R1 stated this has happened multiple times, in the mornings, but doesn’t have the actual dates when this occurred. 3 Out of 5 residents (R3-R5) stated they have never seen or heard about staff pushing residents. Resident R2 did not respond to LPA’s questions, grunted towards and ignored LPA’s questions.
Page 1 Out of 4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

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 4

Control Number 26-AS-20250128124742

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: A HEAVENLY CARE HOME	FACILITY NUMBER: 435201493
	VISIT DATE: 03/14/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On January 31, 2025, LPA Monter interviewed staff S1-S3. 3 Out of 3 staff (S1-S3) stated they have not seen staff push residents. Staff S1 stated he/she has never pushed residents.

On February 26, 2025, LPA Monter interviewed ADM Fontanilla. ADM stated, she has never seen any staff pushing residents. ADM stated she has not heard anyone mention this allegation.

On March 6 & 11, 2025, LPA Monter interviewed Witness W1-W3. 3 Out of 3 Witness interviewed stated they have not seen staff pushing residents in care.

Based on a facility record review, there are no incident reports regarding the alleged push. There are also no incident reports noting any hospitalization's for R2 in late 2025 or 2024.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are 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.

Staff are not providing adequate amounts of food to meet the nutrition needs of residents in care

On January 28, 2025, the Department received a complaint alleging Staff are not providing adequate amounts of food to meet the nutrition needs of residents in care. It has been alleged that facility staff are serving small portions during meals which do not meet the nutrition needs of residents in care.

Page 2 Out of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20250128124742

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: A HEAVENLY CARE HOME	FACILITY NUMBER: 435201493
	VISIT DATE: 03/14/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On January 30 & 31, 2025, LPA Monter interviewed residents R1-R5. R1 stated the facility only provides steamed vegetables. R1 stated the facility only gives small portions with no rice/meat or seconds for residents. R3 stated the facility does not give small portions and provide seconds if requested. R3 stated the facility makes chicken, beef, vegetables, fruits, rice, bread, soup and pasta. R3 stated the facility will make the food they request if they ask. R4 stated the facility gives big portions and provides seconds if he/she asks. R4 stated the facility makes food such as burritos, pancakes, sandwiches, pasta, eggs, salads, chicken and soup. R4 stated the facility will also make the food they request as well. Resident R5 stated he/she is provided enough food to keep him satisfied. Resident R2 did not respond to LPA’s questions, grunted towards and ignored LPA and ignored LPA’s questions.

On January 31, 2025, LPA Monter interviewed staff S1-S3. Staff S1 and S3 stated they follow the facility menu. S1, S2 and S3 stated the facility is providing proteins, vegetables, fruits, vegetables, and other food to meet residents’ nutrition needs. S1, S2 and S3 stated when he/she fills out a plate for a resident, they fill the plate with food to meet the nutrition needs of the resident. S1, S2 and S3 stated if a resident requests for seconds, the staff will provide seconds.

On February 26, 2025, LPA Monter interviewed ADM Fontanilla. ADM stated, the facility provides plenty of food. ADM stated the facility provides fruit, vegetables, carbohydrates, and proteins. ADM stated the facility will also make food sure the food has all the nutrients that residents need. ADM stated the staff will provide residents seconds if they request.

On March 6 & 11, 2025, LPA Monter interviewed Witness W1-W3. 3 Out of 3 Witness interviewed stated they have never observed the facility staff serving small portions for residents meals.

On March 14, 2025, LPA observed residents eating dinner, which included a full plate of the following: fries, chicken, coleslaw, fruits, juice / tea, and yogurt.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are 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.
Page 3 Out of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20250128124742

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: A HEAVENLY CARE HOME	FACILITY NUMBER: 435201493
	VISIT DATE: 03/14/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff entered residents bedroom without knocking

On January 28, 2025, the Department received a complaint alleging Staff entered resident’s bedroom without knocking.

On January 30 & 31, 2025, LPA Manuel Monter interviewed resident R1-R5. R1 stated the staff enter his/her bedroom and don’t knock. R1 stated staff doesn’t tell him/her when they go in. R1 stated he/she hasn’t discussed this issue with the facility ADM. Resident R2 did not respond to LPA’s questions, grunted towards and ignored LPA and ignored LPA’s questions.. Residents R3-R5 stated staff always knock before entering their bedroom.

On January 31, 2025, LPA Manuel Monter interviewed staff S1-S3. 3 Out of 3 staff interviewed stated they knock before entering a resident’s bedroom.

On February 26, 2025, LPA Monter interviewed ADM Fontanilla. ADM stated, staff knock before entering a residents bedroom. ADM stated the staff even knocks before entering a residents bedroom that has the door open.
On March 6 & 11, 2025, LPA Monter interviewed Witness W1-W3. 3 Out of 3 Witness interviewed stated they have observed staff knock on the residents door before entering.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are 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.

Page 4 Out of 4. END OF REPORT.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4