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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201951
Report Date: 05/19/2025
Date Signed: 05/19/2025 05:50:15 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
01/24/2025 and conducted by Evaluator Christine Kabariti
COMPLAINT CONTROL NUMBER: 26-AS-20250124153302
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: 4DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Mario LaganTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff did not adequately supervise resident resulting in resident wandering away from the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Kabariti arrived to the facility unannounced to deliver the finding for the above allegation. LPA met with Desginated Administrator, Mario Lagan.

On 01/24/2025, the Department received the complaint. On 01/30/2025, the initial complaint investigation was conducted. The following documents were obtained to include: LIC500 and R1's physician's report, appraisal/needs and services plan, face sheet, identification and emergency contact information, admission agreement, and police report.

Page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
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 6
Control Number 26-AS-20250124153302
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: 05/19/2025
NARRATIVE
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It was alleged that the staff did not adequately supervise resident resulting in resident (R1) wandering away from the facility.

Based on review of the police report records, it’s noted that R1 was found about 0.2 miles away from the facility running through the parking lot of the shopping center.

On 01/30/2025, staff members and the Licensee were interviewed. Based on staff interview 2 staff were working during the time of the incident. It was stated that on 01/23/2025 R1 left the facility from his/her side door and jumped the fence to go to a sandwich shop across the street of the facility.

2 out of 2 staff stated that they were cleaning and assisting other residents when R1 exited the facility. When staff noticed R1 was missing, staff went to look outside and saw an employee of the sandwich shop waving them down to come there.

The Licensee stated that R1’s new behavior of leaving the facility began in the beginning of January 2025. Licensee states that they were addressing the behavior by talking to the doctor, following up with R1’s case manager, and they were waiting for R1’s insurance to approve a 1:1 staff. Licensee states that R1’s bedroom door does not have door alarms but stated a plan to buy door alarms for his/her room due to his/her exit-seeking behavior. Licensee also stated a plan to replace the battery for the door alarm at the front door to help notify staff when someone opens the doors.

Based on interview with resident (R1), it was stated that he/she likes to leave the facility at least twice a week to go across the street by him/herself, without staff supervision.

The review of R1’s records indicates that R1 is not able to leave the facility unassisted.

On 01/30/2025, LPA observed that R1’s bedroom is located right next to the front door entrance of the facility. The front door alarm was not operable. R1’s private bedroom has a sliding door which leads to the side of the facility. R1’s sliding door had a door alarm, but the door alarm was not operable. Page 2 of 3.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20250124153302
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: 05/19/2025
NARRATIVE
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The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulation, Title 22.

This report was reviewed with Licensee Marie Pendar and a copy of the report and appeal rights were provided.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20250124153302
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2025
Section Cited
CCR
87468.2(a)(4)
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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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Licensee will complete training with all staff regarding resident rights and supervision / safety. Licensee will submit the staff training record to LPA Kabariti via email by POC due date of 05/20/2025.
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Based on observation, interview, and record review the licensee did not ensure resident (R1) was provided supervision to meet R1’s exit seeking behavior resulting in R1 leaving the facility unassisted which poses an immediate health, safety and 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.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
01/24/2025 and conducted by Evaluator Christine Kabariti
COMPLAINT CONTROL NUMBER: 26-AS-20250124153302

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: 4DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Mario LaganTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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2
3
4
5
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9
Staff handled resident in a rough manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Kabariti arrived to the facility unannounced to deliver the finding for the above allegation. LPA met with Desginated Administrator, Mario Lagan.

On 01/24/2025, the Department received the complaint. On 01/30/2025, the initial complaint investigation was conducted. The following documents were obtained to include: LIC500 and R1's physician's report, appraisal/needs and services plan, face sheet, identification and emergency contact information, admission agreement, and police report.

It was alleged that staff handled resident (R1) in a rough manner when walking back to the facility after picking up R1 about 0.2 miles away from the facility. It was alleged that a witness observed staff hit R1 on the left shoulder multiple times to get R1 into the facility. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
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 6
Control Number 26-AS-20250124153302
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: 05/19/2025
NARRATIVE
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Based on review of the police report, 2 witnesses stated to have observed staff hit R1. Witness (W1) stated to have observed one of the staff swing at R1 but was not sure which of the staff hit R1. It was stated that the incident happened in front of the facility. Witness (W2) stated to have observed of the staff hit R1 multiple times to get into the facility.

Resident (R1) was interviewed. Based on interview, R1 denied staff pushing and hitting him/her. R1 did not have any complaints about staff’s treatment towards him/her.

The 2 staff members who were part of alleged incident were interviewed. Based on staff interview, 2 out of 2 staff denied pushing and hitting R1. Staff stated a moment while walking back to the facility where the staff was yelling at R1 to “stop” before crossing the crosswalk as there was a bus coming. Staff denied touching R1 while walking back to the facility and before entering the facility.

Based on review of the police report, on 01/23/2025, there were no bruises or marks on R1’s body. It was noted that R1 did not seem fearful of the staff. Based on LPA’s observation on 01/30/2025, there were no bruises or marks on R1’s body. R1 did not observe to seem fearful of the staff.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated, meaning that although the allegation is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee, Marie Pendar and a copy of the report was provided.

Page 2 of 2.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6