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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201951
Report Date: 03/08/2025
Date Signed: 06/03/2025 04:23:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20240910134450
FACILITY NAME:PENDAR'S RESIDENTIAL CAREFACILITY NUMBER:
435201951
ADMINISTRATOR:MILA VALISTOFACILITY TYPE:
740
ADDRESS:515 TUSCARORA DR.TELEPHONE:
(408) 784-3669
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 6DATE:
03/08/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria PendarTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility staff intimidated resident by not providing basic services/meal services.
Facility staff made false information on a resident's record.
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 03/08/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Maria Pendar, who was briefly interviewed at this time.
Current census was (6) residents.
The purpose of this visit was to deliver the findings of this investigation to this facility, and it's designated Administrator, at this time.
Based on interviews and a review of the forms and documents that were retrieved during this investigation, it was learned that resident, R1, initially moved into this facility several years ago dating back to 2015.
Based on interviews conducted, it was learned that facility staff approached R1 and requested that R1 sign certain forms and documents without thoroughly explaining the nature of the documents and the need for why R1 had to sign them right away.
It was learned that R1 refused to sign the forms and documents and requested that the facility staff provide R1 blank versions of these documents so that R1 could entrust R1's licensed medical professional to
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20240910134450

FACILITY NAME:PENDAR'S RESIDENTIAL CAREFACILITY NUMBER:
435201951
ADMINISTRATOR:MILA VALISTOFACILITY TYPE:
740
ADDRESS:515 TUSCARORA DR.TELEPHONE:
(408) 784-3669
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 6DATE:
03/08/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria PendarTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility staff did not provide care and supervision for resident's catheter.
Facility staff did not update the resident's physician's report.
Facility did not seek timely medical attention to a resident who sustained bladder infection.
Facility is extracting the maximum fund from the resident's trust.
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 03/08/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Maria Pendar, who was briefly interviewed at this time.
Current census was (6) residents.
The purpose of this visit was to deliver the findings of this investigation to this facility, and it's designated Administrator, at this time.
Based on interviews and a review of the forms and documents that were retrieved during this investigation, it was learned that resident, R1, initially moved into this facility several years ago dating back to 2015.
It was learned that R1 had undergone sugery to correct a medical issue and was equipped with a cathether for the first time in R1's life. It was learned that R1 did not adjust well to the cathether and had several issues with it causing R1 to become anxious and agitated. It was learned that R1 requested for facility staff to remove the cathether but staff were not medically trained to be able to assist R1 with this matter.
Facility staff were only able to empty the catheter bag and clean it once it was observed that it had become full.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
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 5
Control Number 26-AS-20240910134450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: PENDAR'S RESIDENTIAL CARE
FACILITY NUMBER: 435201951
VISIT DATE: 03/08/2025
NARRATIVE
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As a result, R1 pulled out the catheter, without any warning, causing severe bodily harm to R1.
It was learned that facility staff who were present did go ahead and contact 911 who responded and took R1 to the hospital for medical treatment.
Based on a review of the facility forms and documents for R1, it was observed that a recent Physician's Report, LIC 602, was updated by R1's responsible licensed medical professional on 09/19/2024 addressing R1's current diagnosis and care needs.
Based on a review of the file for R1, it was learned that R1 had a history of sustaining bladder infections due to R1's inability to urinate on a regular basis. This was one of the issues that was targeted with the surgery so that R1 could have regular visits to the restroom in order to prevent future bladder complications. It was learned that R1 was then equipped with a catheter to facilitate urination and the healing process as well.
Based on a review of the forms and documents submitted by this facility, it was learned that R1 has been a resident at this facility for almost 10 years. During this span of time, all of R1's finances have been handled and paid by a trust that was set up to meet R1's care needs and maintain R1's financial capabilities to remain in an assisted living environment.
It was learned that all invoices for basic services, medications, and ancillary needs were initially paid up front by this facility. This facility would then generate an invoice at the end of the month and submit them to the party responsible for handling and maintaining R1's finances which was done so through R1's trust. It was observed that receipts and all services rendered for each individual month were captured and submitted to the trust in order to receive payment. It was noted that this facility, and it's representative, finally initiated an increase in the monthly basic services fee, back in the latter part of 2023, which then went into effect in February of 2024. All letters notifying the resident and their responsible parties of the rate increase were observed to be present and served with the adequate time frame in mind as well.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20240910134450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: PENDAR'S RESIDENTIAL CARE
FACILITY NUMBER: 435201951
VISIT DATE: 03/08/2025
NARRATIVE
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complete them upon R1's next scheduled appointment.
It was learned that this was met with disdain from the facility staff person who did not pursue the matter any further after R1 refused to comply with their request.
It was learned that these documents were already filled out by the facility staff person assessing R1's capabilities and care needs at that time.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20240910134450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: PENDAR'S RESIDENTIAL CARE
FACILITY NUMBER: 435201951
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2025
Section Cited
CCR
87468.1(a)(1)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights:

(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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The facility designated Administrator stated that all facility staff will undergo training, for no less than one hour in duration, on the subject matter of facility residents rights and how to properly maintain them at all times. A statement of correction, along with copies of the updated training, will be completed and
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This facility was found to be deficient as evidenced by lack of dignity and respect shown towards R1 when attempting update forms and documents without resident consent which posed an immediate threat to the Health, Safety, and Personal Rights of all residents in care.
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submitted into CCL by the due date.
Proof of completed training will involve the topic of training, name of the vendorized trainer, and list of attendee(s).
Type A
03/09/2025
Section Cited
CCR
87468.1(a)(3)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions
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The facility designated Administrator stated that all facility staff will undergo training, for no less than one hour in duration, on the subject matter of maintaing professionalism and upholding facility residents rights at all times. A statement of correction, along with
copies of the updated training, will be
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such as eating, sleeping, or elimination.
This facility was found to be deficient as evidenced by lack of professionalism, dignity and respect shown towards R1 after R1's refusal to comply with staff's demands to update R1's forms and documents which posed an immediate threat to the Health, Safety, and Personal Rights of all residents in care.
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completed and submitted into CCL by the due date.
Proof of completed training will involve the topic of training, name of the vendorized trainer, and list of attendee(s).
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5