435202029-3-21-2024-26-AS-KHOS-D4CRPS-20240415131225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202029
Report Date: 03/21/2024
Date Signed: 03/21/2024 04:36:09 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
09/11/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230911085220

FACILITY NAME:	FLINTCREST HOUSE		FACILITY NUMBER:	435202029
ADMINISTRATOR:	FE PUNZALAN		FACILITY TYPE:	735
ADDRESS:	2043 FLINTCREST DRIVE		TELEPHONE:	(408) 533-5124
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY:	6	CENSUS: 6	DATE:	03/21/2024
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Administrator, Fe Punzalan		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Facility staff yell at resident
Facility staff physically hurt resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation and deliver the findings. LPA Rai met with Administrator, Fe Punzalam and stated the purpose of the visit. LPA Rai observed 5 residents and 3 staff during the visit.

On 09/07/2023, resident R1 was admitted to the hospital after a 5150 psychiatric hold placed by the local law enforcement officer after resident was “very agitated and confrontational”. The resident had an emotional outburst wherein the resident hit the sliding door in R1’s room and pulled on the TV monitor in the living room from the mantel on the wall and brought it down to the table below.

R1 was discharged from the hospital and transported back at the facility after being treated for other underlying health problems.

Continuation on LIC 9099-C, Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

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 5

Control Number 26-AS-20230911085220

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: FLINTCREST HOUSE	FACILITY NUMBER: 435202029
	VISIT DATE: 03/21/2024

NARRATIVE

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Page 2 of 3.

On 09/11/2023, the Department received a complaint with the above allegation. On 09/19/2023, the Department conducted the initial investigation compliant visit at the facility. During investigation visit, 1 resident (R1) and 2 staff (S1-S2) were interviewed who were present during the incident and where able to recall the series of events.

On 9/9/2023, the resident had an emotional outburst wherein resident hit the sliding door in R1’s room and pulled on the TV monitor in the living room from the mantel on the wall and brought it down to the table below. R1 was taken to the hospital for 5150 hold and at the hospital R1 reported to physician of left wrist pain after punching window at the facility. Per Hospital Psychiatric Consultation Note dated 9/9/2023, R1 stated “I was violent at my house” stating the facility staff hurt and yelled at the resident.

On 9/19/2023, the Department conducted interviews with 2 staff and 1 resident. 2 Out of 2 staff stated the facility staff do not yell or physically hurt residents at the facility. 2 Out of 2 staff stated R1 pulling on the TV and subsequently hurt R1’s hand. Staff S1 stated he/she has not observed facility staff hurting the residents. Staff S1 stated the fireman at the facility assessed R1 and stated R1 hurt the hand while pulling the TV. Staff S1 stated the facility staff are mandated report and knows the responsibility to report any abuse to the Department. Staff S1 stated the staff are aware if they yell at R1, R1’s behavior will escalate, so during the incident on 9/7/2023, the staff tried to stay calm. R2 stated “no” when asked if facility staff hurt or yell at the residents at the facility. R2 asked about facility administrator and R2 laughed in response and stated “nice” and “doesn’t yell”.

During the time of the investigation, LPA Rai attempted to interview resident (R1) but R1 refused to be interviewed. During today’s visit, resident (R1) was observed smiling and hugging staff during the visit.

Based on the review of Incident Report dated 9/7/2023, staff and firemen noticed R1’s hand was bleeding from grabbing the TV off the wall. On 9/19/2023, LPA Rai toured the living room and did not observe the tv mounted on the wall.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20230911085220

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: FLINTCREST HOUSE	FACILITY NUMBER: 435202029
	VISIT DATE: 03/21/2024

NARRATIVE

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Page 3 of 3.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Fe Punzalam and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5