435201951-10-13-2023-26-AS-KHOS-D9LT8Q-20240930143045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201951
Report Date: 10/13/2023
Date Signed: 10/13/2023 03:38:20 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
10/05/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20231005210200

FACILITY NAME:	PENDAR'S RESIDENTIAL CARE		FACILITY NUMBER:	435201951
ADMINISTRATOR:	MILA VALISTO		FACILITY TYPE:	740
ADDRESS:	515 TUSCARORA DR.		TELEPHONE:	(408) 784-3669
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 5	DATE:	10/13/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mila Valisto		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident in care is not being fed.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) David Marrufo and Mita Partoza conducted an unannounced complaint investigation visit and met with Administrator Mila Valisto and Licensee Marie Pendar.

During visit, LPA Marrufo interviewed 5 out of 5 residents, interviewed Administrator Valisto, Licensee Pendar, and staff S1. LPAs observed the lunch meal service and observed facility food storage areas. LPAs observed resident records during visit.

During interview, resident R1 stated that R1 sometimes refuses meals because R1 does not want to gain weight. LPAs observed staff assist R1 with feeding during visit.

See LIC9099-C for more information. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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 3

Control Number 26-AS-20231005210200

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: PENDAR'S RESIDENTIAL CARE	FACILITY NUMBER: 435201951
	VISIT DATE: 10/13/2023

NARRATIVE

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Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegation is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Mila Valisto and a copy of this report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

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
10/05/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20231005210200

FACILITY NAME:	PENDAR'S RESIDENTIAL CARE		FACILITY NUMBER:	435201951
ADMINISTRATOR:	MILA VALISTO		FACILITY TYPE:	740
ADDRESS:	515 TUSCARORA DR.		TELEPHONE:	(408) 784-3669
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 5	DATE:	10/13/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mila Valisto		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility has a resident who depends on others to perform all activities of daily living

INVESTIGATION FINDINGS:

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During visit, LPAs observed resident R1 comb R1's hair unassisted and observed R1 bring a cup of water to R1's mouth and drink from a straw without assistance.

This agency has investigated the complaint allegation listed. Based on interviews, review of records, and observations, the CCLD has found that the complaint allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report was reviewed with Mila Valisto and a copy of this report was provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3