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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202081
Report Date: 03/10/2026
Date Signed: 03/10/2026 04:31:06 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
01/21/2026 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20260121081629

FACILITY NAME:CALIFORNIA RESIDENTIAL FACILITYFACILITY NUMBER:
435202081
ADMINISTRATOR:SASHI LATA KUMARFACILITY TYPE:
735
ADDRESS:3781 POLTON PLACE WAYTELEPHONE:
(408) 390-6172
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 6DATE:
03/10/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Sashi KumarTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility weekend activities are visiting the licensee's other home with no activities provided
INVESTIGATION FINDINGS:
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On January 21, 2026 the Department received a complaint alleging Facility weekend activities are visiting the licensee's other home with no activities provided

On January 21, 2026, the Department interviewed Witness W1. W1 stated the Administrator only takes the residents into her home. W1 stated the residents are confined in 1 room.

On January 24, 2026, LPA Manuel Monter interviewed Administrator (ADM) Sashi Kumar. ADM stated the is always activities at the care home and during the weekends. ADM stated she treats the residents like family. ADM stated she will sometimes go out to family events and take the residents as well to join in the festivities. ADM stated the residents are not just seated in a room. ADM stated the residents are provided activities.

Page 1 Out of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 11
Control Number 26-AS-20260121081629
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: CALIFORNIA RESIDENTIAL FACILITY
FACILITY NUMBER: 435202081
VISIT DATE: 03/10/2026
NARRATIVE
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On January 27 & 29, 2026, LPA Manuel Monter interviewed residents R1-R6. R1 stated he/she did go on an outing on Saturday. R1 stated he/she doesn’t remember where he/she went. R1 stated he/she was drawing and playing. R3 stated he/she doesn’t know what he/she did on Saturday. R3 stated he/she thinks he/she stayed home on the weekend. R3 stated some of the activities they do is coloring and writing. R3 stated they go out and eat tacos and get fruit drinks on the weekend.

R4 stated on Saturday, he/she went with other residents. R4 stated he/she doesn’t know where he/she went, but confirmed she went with ADM (Sashi). R6 stated he/she doesn’t remember what he/she did on Saturday. R6 stated the home does provide activities. R6 stated they play games, color, Zumba, go to the mall or the park.2 Out of 6 residents ( R2, R5) did not respond to questions posed and did not provide relevant information regarding the allegations.

On February 29, 2026, LPA Manuel Monter interviewed staff S1-S3. Staff S1 and S2 stated the facility does provide activities for the residents. S1 and S2 stated last weekend, the residents were taken to a birthday party at hayward for one of the Administrators family members. S1 and S2 stated the residents are like family and will join in the party as well. S1 and S2 stated at the party, the residents were eating the food, dancing, playing games, and singing.

S3 stated the facility does provide activities for the residents. S3 stated at the care home they do the following activities based on the residents choices: outings, going to the mall, going to the local park, singing, dancing, watch movies, paint nails, play with the cats. S3 stated the activities are based on the residents choice. S3 stated last weekend, the residents were taken to an outing but doesn’t have knowledge. S3 stated on Saturday, he/she only clocked in to assist the residents in their morning routine but didn’t go.

On March 1, 2026, LPA Manuel Monter interviewed staff S4. S4 stated he/she has observed the facility conducting activities when he/she works at the facility. S4 stated the residents like to color, play board games, listen to music. S4 stated there hasn’t been a time when residents were at the care home with no activities.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are 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. Page 2 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 11