435202031-11-21-2024-26-AS-KHOS-DBCR46-20241125114102

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202031
Report Date: 11/21/2024
Date Signed: 11/21/2024 04:41:38 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
04/29/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20240429120348

FACILITY NAME:	PIEDMONT ADULT DAY PROGRAM (PADPRO)		FACILITY NUMBER:	435202031
ADMINISTRATOR:	RANULFO DIEGO GARCIA		FACILITY TYPE:	775
ADDRESS:	1325-1333 PIEDMONT RD #109-110		TELEPHONE:	(408) 347-0402
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95131
CAPACITY:	75	CENSUS: 72	DATE:	11/21/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Ranulfo Garcia		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

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Client sustained unexplained bruises at the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Administrator (ADM) Ranulfo Garcia.

On 4/29/2024, the Department received a complaint with the allegation that client sustained unexplained bruise at the facility.

On 5/3/2024, the Department conducted an initial investigation visit.

LPA interviewed 4 staff and toured the facility.

LPA obtained 5 residents documents.

Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20240429120348

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: PIEDMONT ADULT DAY PROGRAM (PADPRO)	FACILITY NUMBER: 435202031
	VISIT DATE: 11/21/2024

NARRATIVE

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Client sustained unexplained bruises at the facility:
Client C1's family member (FM) observed C1 with bruise when C1 came home. FM thought C1 obtained the bruise at the day program.

On 5/3/2024, LPA interviewed Administrator (ADM). ADM stated the Program Director (PD) has more detail information about the incident. ADM stated the facility had a meeting with client C1's family member (FM), and Service Coordinator for C1's incident.

LPA interviewed Program Director (PD). PD stated the facility received an email from C1's service coordinator (SC) stating C1's family member (FM) saying C1 came home with bruise 2 - 3 days before FM reported to SC. PD stated the facility conducted an internal investigation and nothing was found regarding C1's bruise in the day program.

PD stated the facility had a meeting with FM and SC. The facility staff were thinking the bruise might come from the seat belt of the taxi. C1 was agitated and aggressive toward the taxi driver during the transportation to the day program. It could have been the seat belt that was tightening on C1's chest when C1 was moving the body forward. PD stated there were no any incident on those days regarding C1 in the day program. PD stated the clients in the day program who were around C1 are not aggressive. PD stated they agreed that the facility is going to do body check on C1 when C1 arrives the facility and leaves the facility. PD stated after the incident the facility did not find any bruise on C1.

LPA interviewed a staff S1. S1 stated C1 is in his/her group and staff S2 is direct working with C1. S1 stated he/she has no observations of abuse from staff to clients, no observations of S2 hitting or hurting C1, and no observations of staff hurting or hitting C1.

S1 stated a week ago, the taxi driver (TD) who brought C1 to the facility came to the front desk stating C1 was banging the grill that was put between driver and customer of the taxi. TD stated C1 was not sitting properly and was at the edge of the seat during the transportation. S1 stated he/she went out to see C1 and talked to C1. S1 stated he/she saw C1 was with and on the seat belt in the taxi. TD stated C1 was observed pointed the pencil on his/her arm when he/she was doing his/her activity.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240429120348

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: PIEDMONT ADULT DAY PROGRAM (PADPRO)	FACILITY NUMBER: 435202031
	VISIT DATE: 11/21/2024

NARRATIVE

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LPA interviewed staff S2. S2 is a Spanish speaker. LPA used translation software to communicate with S2. S2 is a staff direct taking care of 3 clients including client C1. S2 did not observed anyone hitting C1 or any clients S2 knew and saw C1's bruise but did not know what happened to C1. C1 always locked self in the restroom for a while when C1 was using restroom. C1 hit and broke the faucet in the restroom last week.

Based on the review of C1's appraisal needs and service plan, C1 may resort to self injurious behavior.

Based on the review of the picture of C1's bruise on the chest, it cannot be excluded the possibility that the bruise caused by the seat belt.

Based on the review of incident reports sent to CCL office regarding C1, there is no incident report of R1 in February 2024, March 2024, April 2024, and May 2024.

Based on the interview and records reviewed, no evidence to indicate C1 was hit or was abused in the day program facility.

Based on investigation, interviews conducted and records reviewed , the Department found that the above allegation is 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 allegations did or did not occur.

No citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. A copy of this report was provided to ADM.

Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

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