435202124-7-20-2023-26-AS-RMAO-CVKS2C-20230911132918

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202124
Report Date: 07/19/2023
Date Signed: 07/20/2023 08:36:44 AM

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
03/29/2023 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230329141328

FACILITY NAME:	BEYOND POTENTIAL LEARNING CENTER		FACILITY NUMBER:	435202124
ADMINISTRATOR:	CARMELA MAGPAYO		FACILITY TYPE:	775
ADDRESS:	1753 SOUTH MAIN STREET		TELEPHONE:	(408) 438-0442
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	75	CENSUS: 65	DATE:	07/19/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Melissa Ramos		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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A staff member verbally abused a resident
A staff member threatened a resident

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Simi Rai and Manuel Monter and Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced inspection/investigation visit to conclude and deliver investigation of the above allegations. LPAs and LPM met with Administrator Melissa Ramos and stated the purpose of today's visit.

On 04/7/2023 and 4/18/2023, the Department conducted investigation and inspection wherein staff and clients were interviewed. LPAs also obtained the following documentation: 4 individualized personal plans, 4 client needs and services plans, staff schedule and resident attendance for the week of March 27th 2023-April 1st 2023, and resident roster.

Continuation on LIC 9099-C.
Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230329141328

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: BEYOND POTENTIAL LEARNING CENTER	FACILITY NUMBER: 435202124
	VISIT DATE: 07/19/2023

NARRATIVE

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Page 2 of 2. On 04/7/23, LPAs met and interviewed staff (S1). S1 stated that sometime in March when drop-off it was raining, and the door of the van was opened wherein resident (R1 said to him/her "shut the fucking door," S1 replied, "let me put R...." S1 stated that R1 threw his/her lunch bag at S1. S1 then flipped him/her off. S1 stated that another staff (S2) who was the designated driver who witnessed the incident but no longer works at the facility. On 04/18/2023, the Department conducted interviews with clients wherein they stated that staff at the facility are 'nice.'

On 07/19/2023, the Department interviewed Administrator (ADM) who is aware of R1's use of foul language or profane language when he/she hears something. ADM stated that R1's Service Coordinator from San Andreas Regional Center (SARC) and family wherein R1's behavior has been discussed when he/she use profanity and accusing staff. ADM stated that when R1 hears other client use of profane language, R1 would turn around and accused that staff said the profane language. ADM stated that staff at the facility does not threatened R1. ADM stated that R1 is no longer a client at this program.

On 07/19/2023, the Department interview staff (S2 and S3) at R1's ARF home. At 10:32AM, staff (S2) was interviewed and provide information about R1's behavior, S2 stated that when R1 hears another client being upset using profane language, R1 would get upset and accused staff why they use profane language or bad words at him/her. S3 stated that when R1 hears another resident using bad words, he/she will copy it but lately he/she is doing fine.

On 7/19/2023,at 10:17AM, ARF Administrator (ARF ADM) was interviewed. ARF ADM stated that he/she is the new ARF ADM for the past 20 days, he/she said aware of R1's aggressive behavior but has not observed R1's use of profane language.

The Department has investigated the above allegation. Based on observation and interview, the Department has determined 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 the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Melissa Ramos and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

LIC9099 (FAS) - (06/04)

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