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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201758
Report Date: 10/18/2023
Date Signed: 10/18/2023 04:58:57 PM

Unsubstantiated


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
06/28/2021 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20210628130510
FACILITY NAME:NEO NICHOLAS MANORFACILITY NUMBER:
435201758
ADMINISTRATOR:CHRISTIA-MARIE MENDOZAFACILITY TYPE:
735
ADDRESS:14961 RIDGETOP DRIVETELEPHONE:
(408) 708-7928
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 6DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Maria GrieveTIME COMPLETED:
02:11 PM
ALLEGATION(S):
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Resident was choked by a staff.
Resident was pushed up against a wall by a staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation visit to deliver investigation findings and met with House Manager (HM) Maria Grieve.

On 06/28/2021, the Department received a complaint regarding the above allegations. An initial complaint investigation visit was conducted on 07/01/2021. Facility staff S1, S2, S3 and ADM were interviewed.

Rosters of clients and staff, R1's Physician's report, Functional Capability, Appraisal Needs and Services Plan, and incident reports were obtained.

Continued, see LIC 9099-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: 1 of 6
Control Number 26-AS-20210628130510
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: NEO NICHOLAS MANOR
FACILITY NUMBER: 435201758
VISIT DATE: 10/18/2023
NARRATIVE
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esident was choked by a staff:
Resident was pushed up against a wall by a staff:

On 07/01/2021, LPA interviewed staff S2. S2 stated he/she did not choke or push R1 and did not hear or observe that R1 was choked by anyone or was pushed by anyone.

On 9/23/2021, LPA interviewed staff S1. S1 denied the allegation that R1 was pushed or was choked by staff. S1 stated he/she never observed or heard that R1 was choked by staff or was pushed by staff. S1 stated he/she asked R1 about the allegations. R1 stated the allegations did not happen, and he just faked it.

On the same day, LPA interviewed Administrator (ADM). ADM stated he/she did not have knowledge of the incidents claimed by R1 that R1 was pushed or was choked by staff. ADM stated he/she did not receive any reports that resident was pushed or was choked by staff.

LPA reviewed incident reports (SIRs) of R1, and found R1 had some episodes of claiming pains, but after evaluated by paramedics, they turned out to be false claims. During R1 hospitalization, he/she claimed similar allegations, and the doctor did not observe any bruises on R1' body.

Based on the documents reviewed and the interviews conducted, there was no evidence to show that R1 was choked by staff or was pushed up against a wall by staff.

The Department has investigated the above allegations. Based on the investigation, observations, records reviewed, and interviews conducted, the Department has 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 allegation did or did not occur.

Exit interview was conducted with HM. No citation was noted. The report was provided to HM for signature. A copy of the report was provided. to HM.

Page 2 of 2.
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: 2 of 6
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
06/28/2021 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20210628130510

FACILITY NAME:NEO NICHOLAS MANORFACILITY NUMBER:
435201758
ADMINISTRATOR:CHRISTIA-MARIE MENDOZAFACILITY TYPE:
735
ADDRESS:14961 RIDGETOP DRIVETELEPHONE:
(408) 708-7928
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 6DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Maria GrieveTIME COMPLETED:
02:11 PM
ALLEGATION(S):
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Resident eloped from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation visit to deliver investigation findings and met with House Manager (HM) Maria Grieve.

On 06/28/2021, the Department received a complaint regarding the above allegations. An initial complaint investigation visit was conducted on 07/01/2021. Facility staff S1, S2, S3 and ADM were interviewed.

Rosters of clients and staff, R1's Physician's report, Functional Capability, Appraisal Needs and Services Plan, and incident reports were obtained.

Continued, see LIC 9099-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: 3 of 6
Control Number 26-AS-20210628130510
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: NEO NICHOLAS MANOR
FACILITY NUMBER: 435201758
VISIT DATE: 10/18/2023
NARRATIVE
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Resident eloped from the facility:
On 07/01/2021, LPA interviewed staff S2. S2 stated R1 eloped from the facility several times including the incident on 6/25/2021. LPA interviewed staff S1 and S3, both stated R1 eloped more than one time including the incident on 6/25/2021. LPA interviewed ADM, ADM confirmed that R1 eloped from the facility including 6/25/2021 and 6/28/2021.

On 09/24/2021, LPA reviewed the R1's elopement incident reports that the facility reported, it showed that R1 eloped from the facility on 6/23/2021, 6/25/2021 and 6/28/2021.

On 6/23/2021, R1 walked out from the facility main door after 4:20PM, facility staff immediately was following R1 and tried to redirect R1 to return to facility but failed to get R1 back to facility. The facility staff then called 911 around 4:25PM. Around 5:08PM, the sheriff called the facility and said that R1 was sent to hospital. The hospital called the facility to send R1 back to facility via taxi. The facility staff waited at the facility, but R1 did not return to facility.

On 6/24/2021, at 9:00AM, the facility called R1's father, and he said R1 was in a hospital in San Francisco. At 1:40PM, the facility received a phone call from police that the police found R1, and R1 was ready to pick up. At 4:42PM, facility staff picked up R1 and returned to facility.

On 6/25/2021, around 3:30PM, R1 was attempting to run away from the facility. Facility staff redirected R1, but R1 still wanted to run away from the facility. Facility staff called 911 and called R1's family immediately. The Sheriff came in facility to calm R1 down. After the sheriff left, R1 ran out again, staff followed R1 immediately and called 911 again. The Sheriff came and calmed R1 down. After the sheriff left, R1 ran away again. Staff tried to redirect R1 and were following R1 and called 911 again. R1 was sent to hospital for evaluation and treatment.

On 6/28/2021, R1 was sent back to facility from hospital, R1 ran away when R1 got out of car. Facility staff followed R1 and redirected R1. The facility staff was able to redirect R1 and got R1 back to facility.

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: 4 of 6
Control Number 26-AS-20210628130510
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: NEO NICHOLAS MANOR
FACILITY NUMBER: 435201758
VISIT DATE: 10/18/2023
NARRATIVE
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Based on interviews conducted, and documents reviewed, R1 has had several elopements from facility. Although the facility staff did try their best to get R1 back to facility after R1's elopements, the facility staff did not prevent R1 from eloping from the facility effectively. The facility did not provide the necessary care and supervision to residents. The facility did not have effective measures to prevent residents to elope from facility.

The Department has conducted an investigation of the above allegations. Based on observations, records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D.

Exit interview was conducted with HM. This report and LIC9099-D were provided to HM for signature. A copy of the report was provided to HM.

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: 5 of 6
Control Number 26-AS-20210628130510
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: NEO NICHOLAS MANOR
FACILITY NUMBER: 435201758
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2023
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
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Administrator stated to conduct staff training in ensure care and supervision are provided to residents to prevent elopement, and to submit the Plan of Correction to CCL by POC due date.
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This requirement was not met as evidence by: Based on interviews and records reveiw, R1 eloped from the facility more than one time. This posed an immediate health and safety rsik to resident 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: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6