435201736-12-8-2023-26-AS-RMAO-CZQKYD-20240122071854

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201736
Report Date: 10/18/2023
Date Signed: 12/08/2023 08:09:22 AM

Substantiated

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
10/18/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20211018085500

FACILITY NAME:	ABORN ADULT CARE HOME		FACILITY NUMBER:	435201736
ADMINISTRATOR:	DR. SHACY LEE RIVERA		FACILITY TYPE:	735
ADDRESS:	2868 ABORN ROAD		TELEPHONE:	(408) 223-1108
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	6	CENSUS: 6	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Arielle Teodoro		TIME COMPLETED:	03:21 PM

ALLEGATION(S):

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Facility is under staffed.
Licensee is charging residents for care not received.

INVESTIGATION FINDINGS:

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The purpose of this visit is to amend the finding delivered on 10/18/2023.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finds and met with current Administrator (CADM) Arielle Teodoro.

On 10/18/2021, the Department received a complaint with the above allegations.

On 10/22/2021, an initial investigation visit was conducted, Administrator (ADM) and 5 staff were interviewed. The food supplies was inspected. Staff schedules and residents medical documents were obtained.

Continue on LIC9099-C. Page 1 of 3.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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 9

Control Number 26-AS-20211018085500

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: ABORN ADULT CARE HOME	FACILITY NUMBER: 435201736
	VISIT DATE: 10/18/2023

NARRATIVE

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Facility is under staffed:
Licensee is charging residents for care not received:

On 10/22/2021, the Department interviewed Administrator (ADM). ADM stated the facility had a resident needed 24 hours 1:1 care, 3 residents needed 1:1 care in the PM shift. ADM stated the released schedule posted on the refrigerator was for the regular staff, and he/she always worked to add more staff to work at the facility. ADM stated regular staff might not know exactly how many staff would work at that shift in advance. ADM stated usually the facility had 5 or 6 staff at the PM shift. ADM stated the facility had at least 3 staff all the time at the facility.

On the same day, the Department interviewed 5 staff (S1 - S5). S1 stated the facility had shortage of staffing until last month that the facility hired more staff. S2 and S5 stated the facility had under staffing issue in the PM shift. Staff S3 and S4 stated there were no staff shortage issue.

The Department inquired SARC if the facility had staff shortage issue. On 12/14/2021, the Department received a response from SARC that the facility's 3 individuals received 1:1 care support.

Based on reviewing the facility staff schedule, the facility had staff shortage for 6 residents with 4 individuals need 1:1 care.

Based on the records reviewed and interviews conducted, the facility had some shifts under staffing even though not all the time under staffing.

The Department inquired SARC, and SARC confirmed on 12/14/2021 that SARC provided the facility 1:1 supplemental support for 3 individuals. The facility charged residents based on the service provided to residents specified in the residents' care plans. The facility had under staff to provide 4 residents 1:1 care. The facility charged several residents with 1:1 care but the facility did not have sufficient staff to provide 1:1 care to the clients who were charged for 1:1 care.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 9

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
10/18/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20211018085500

FACILITY NAME:	ABORN ADULT CARE HOME		FACILITY NUMBER:	435201736
ADMINISTRATOR:	DR. SHACY LEE RIVERA		FACILITY TYPE:	735
ADDRESS:	2868 ABORN ROAD		TELEPHONE:	(408) 223-1108
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	6	CENSUS: 6	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Arielle Teodoro		TIME COMPLETED:	03:21 PM

ALLEGATION(S):

1
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8
9

Licensee is falsifying facility records.

INVESTIGATION FINDINGS:

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11
12
13

The Purpose of this visit is to amend the finding delivered on 10/18/2023 from unfound to unsubstantiated due to additional information.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finds and met with curent Administrator (CADM) Arielle Teodoro.

On 10/18/2021, the Department received a complaint with the above allegations.

On 10/22/2021, an initial investigation visit was conducted, Administrator (ADM) and 5 staff were interviewed. a food supplies check tour was conducted. Staff schedules and residents medical documents were obtained.

Continue on LIC9099-C. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 26-AS-20211018085500

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: ABORN ADULT CARE HOME	FACILITY NUMBER: 435201736
	VISIT DATE: 10/18/2023

NARRATIVE

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Licensee is falsifying facility records:

On 10/22/2021, the Department interviewed ADM and two staff (S1, S3). S1 stated the facility had 2 schedules, one to show LPA for checking, and one for real schedule. S3 stated the schedule posted on the refrigerator was the schedule that the staff confirmed, and Administrator continued to notify more staff to work. ADM stated the schedule posted on the refrigerator was the schedule for regular staff, he/she continued to work on to add more staff to work for the facility. ADM stated the updated schedule was on his/her computer.

Based on reviewing the schedules collected by LPA, the schedules show the facility under staffing. The schedules in ADM's computer which LPA did not receive might have more staff than the schedules LPA collected. Based on the interviews and documents reviewed, the schedule posted and the schedule updated were under staffing. The schedules were not real schedules and all under staffing. ADM kelp updating staff schedule to add more staff, but there were no sign of intention of Licensee/Administrator to falsity facility records.

The Department has investigated the above allegation. Based on interview, record review, and observation the department has found the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to show the alleged violations did or did not occur.

No citations noted at today’s compliant investigation visit. Exit interview was conducted with current Administrator (CADM). This report was provided to CADM for signature. A copy of this report was emailed to CADM.

Page 2 of 2.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 9

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
10/18/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20211018085500

FACILITY NAME:	ABORN ADULT CARE HOME		FACILITY NUMBER:	435201736
ADMINISTRATOR:	DR. SHACY LEE RIVERA		FACILITY TYPE:	735
ADDRESS:	2868 ABORN ROAD		TELEPHONE:	(408) 223-1108
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	6	CENSUS: 6	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Arielle Teodoro		TIME COMPLETED:	03:21 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not providing residents adequate meals.
Facility staff are not adequately trained.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finds and met with Current Administrator (CADM) Arielle Teodoro.

On 10/18/2021, the Department received a complaint with the above allegations.

On 10/22/2021, an initial investigation visit was conducted, Administrator (ADM) and 5 staff were interviewed. a food supplies check tour was conducted. Staff schedules and residents medical documents were obtained.

Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 26-AS-20211018085500

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: ABORN ADULT CARE HOME	FACILITY NUMBER: 435201736
	VISIT DATE: 10/18/2023

NARRATIVE

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Facility is not providing residents adequate meals:

On 10/22/2021, the Department interviewed 5 staff (S1 - S5). 3 Out of 5 staff stated sometimes the facility did not have sufficient food for residents. Staff S3 stated he/she was the one ordered the groceries, and the groceries were delivered to the facility every Sundays. S3 stated he/she ordered a lot of food for the facility.

On the same day, the Department interviewed ADM. ADM stated the groceries delivered to the facility once every week. ADM stated the facility never had a shortage of food. The facility provided the receipts that the facility ordered the groceries to LPA.

LPA toured the facility and checked the food supplies. 2 day perishable food supplies and 7 day nonperishable food supplies were observed sufficient.

Facility staff are not adequately trained:

On 10/22/2021, the Department interviewed ADM. ADM stated the staff received orientation training, shadowing with staff to take care of residents, and the staff went over the program design, IPP, special needs, and medications training. ADM stated the staff received sufficient training to provide care to residents.

On the same day, the Department interviewed 5 staff (S1 - S5). 5 out 5 stated they received DSP I and II training. S1 stated he/she was able to shadow with staff to learn how to provide care to residents. S2 stated he/she received yearly training from SARC and there was a nurse who came to the facility to provide the training. S2 stated ADM provided the training for medications and policies. S3 stated he/she received orientation training when he/she got hired. S4 stated he/she received orientation training and was able to shadow with staff to learn how to provide care to residents. S5 stated the facility provided a lot of training to take care of residents. 5 out of 5 stated they believed they received sufficient training and have confidence to provide care to residents All of them stated they did not know what kinds of training were provided to new hires.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 26-AS-20211018085500

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: ABORN ADULT CARE HOME	FACILITY NUMBER: 435201736
	VISIT DATE: 10/18/2023

NARRATIVE

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The Department has investigated the above allegation. Based on interview, record review, and observation the department has found the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to show the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Current Administrator (CADM) and a copy of the report was provided.

Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 26-AS-20211018085500

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: ABORN ADULT CARE HOME	FACILITY NUMBER: 435201736
	VISIT DATE: 10/18/2023

NARRATIVE

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The Department has investigated the above allegation and the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D.

This report was reviewed with the current Administrator (CADM) and a copy of the report and appeal rights was provided.

Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 26-AS-20211018085500

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: ABORN ADULT CARE HOME	FACILITY NUMBER: 435201736
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/25/2023 Section Cited CCR 85065(b)	1 2 3 4 5 6 7	85065 Personnel Requirements (b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.	1 2 3 4 5 6 7	Administrator stated the facility will submit a plan of correction by the POC due date to hire more staff to provide enough care to residents.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on the records reviewed and interviews, the facility was understaffing and did not hire enough staff to provide 1:1 care to residents which poses an potential health, safety, or personal rights risk to a person in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

Page: 9 of 9