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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201736
Report Date: 02/10/2024
Date Signed: 02/13/2024 05:30:20 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
02/09/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240209105051
FACILITY NAME:ABORN ADULT CARE HOMEFACILITY NUMBER:
435201736
ADMINISTRATOR:ARIELLE TEODOROFACILITY TYPE:
735
ADDRESS:2868 ABORN ROADTELEPHONE:
(408) 223-1108
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:6CENSUS: 6DATE:
02/10/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Staff Member David PadillaTIME COMPLETED:
10:05 AM
ALLEGATION(S):
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The facility did not maintain the room temperature between 68 degree F and 85 degree F.
INVESTIGATION FINDINGS:
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On February 9, 2024, the department received a complaint alleging the facility did not maintain the room temperature between 68 degree F and 85 degree F.

This report is being amended due to additional information being provided.

On February 10, 2024, LPA Manuel Monter conducted an unannounced complaint investigation visit. LPA met staff member David Padila (S1). S1 contacted Administrator (ADM) Arielle Teodoro, and informed her the purpose of the visit. LPA toured the home inside and out with S1 and measured facility temperature using a thermometer. LPA measured resident bedroom #2 at 58 degrees F. LPA measured resident bedroom #3 at 58 degrees F. LPA measured resident bedroom # 1 at 58 degrees F. LPA observed facility thermostat temperature at 56 degrees F, with a paper sign stating, "Please Do Not Turn On Heater..Ty.." (Photograph was taken). LPA measured room temperature of the area across from the dinning room and adjacent from bedroom #2. LPA measured Kitchen room temperature at 58 degrees F.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
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-20240209105051
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: ABORN ADULT CARE HOME
FACILITY NUMBER: 435201736
VISIT DATE: 02/10/2024
NARRATIVE
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On February 10, 2024 LPA interviewed staff S1 to S3. 3 Out of 3 staff confirmed that the facility is cold and the heater is not working. 2 Out of 3 staff stated they do not remember when the heater became broken. 1 Out of 3 staff stated the facility heater has not been working since the end of December.
LPA interviewed residents R1-R5. 3 Out of 5 residents are non-verbal and unable to answer LPA's questions. 2 Out of 5 residents stated the facility has been cold since late December - late January.

On February 10, 2024 LPA interviewed Licensee. Licensee stated, a contractor came to the facility last week and they will replace the heating system. LN stated it was delayed due to the storm. LN stated the facility was using space heaters in the meantime while they wait for the heater to get repaired. LPA informed ADM that, while touring the home, LPA did not observe a space heater in resident bedroom #1, which was occupied by a resident. LPA did not observe a space heater in the dinning room where two residents were at. LPA did not observe a space heater in resident bedroom #2. LPA observed a space heater in resident bedroom #3, facing one of the residents beds.

On February 13, 2024 LPA interviewed ADM. ADM stated she was informed by a staff member that the heater was not working on January 12, 2024. ADM stated she informed licensee the same day. ADM stated the contractors arrived to check the heater the same day. The contractors informed the ADM the heater had a breaker issue, which was fixed, but another issue was found during their inspection. The contractors informed ADM that the heater had a separation inside the chambers, which had a strong chance of allowing the exhaust gases into the home. ADM stated the potential of the heaters exhaust entering the home, was the reason for putting up the sign stating "please don't turn on heater." ADM stated the reason for the delay of addressing the broken heater was due to contractors availability and were waiting for supplies to change the heater. On February 13, 2024, LPA measured facility temperature at 70 degrees F during visit.

According to Title 22 code of regulations, 80088 Furniture, Fixtures, Equipment, and Supplies (a)(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

The Department has investigated the above allegation. Based on observations, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Administrator Arielle Teodoro and a signed copy of this report was provided along with appeal rights.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20240209105051
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: ABORN ADULT CARE HOME
FACILITY NUMBER: 435201736
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/14/2024
Section Cited
CCR
80088(a)(1)
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80088 Furniture, Fixtures, Equipment, and Supplies (a)(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).
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ADM will send plan of action on how the facility shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). ADM stated she will send plan of action by POC date, 02/14/2024
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Based on observation & interviews, the facility temperature was measured at 58 degrees F. Staff and residents interviewed stated the heater has been broken for several weeks. This poses/posed an immideate health, safety or personal rights risk to persons in care.
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Type A
02/14/2024
Section Cited
CCR
80064(a)(2)
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80064 Administrator - Qualifications and Duties (a)(2) Knowledge of the requirements for providing the type of care and supervision needed by clients, including ability to communicate with such clients. This requirement was not met as evidenced by;
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ADM stated she will send letter of understanding regarding the regulation. ADM stated she will send letter by POC date, 2/14/2024.
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Based on observastion and interviews conducted, the facility did not have a heater since Janurary 15, and subsquently the tempreture of the home was measured at 58 degrees F. This poses/posed an immideate health, safety or personal rights risk to persons 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: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3