<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202124
Report Date: 12/19/2023
Date Signed: 12/19/2023 11:05:07 AM

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
10/06/2023 and conducted by Evaluator Simranjit Rai
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20231006134901
FACILITY NAME:BEYOND POTENTIAL LEARNING CENTERFACILITY NUMBER:
435202124
ADMINISTRATOR:CARMELA MAGPAYOFACILITY TYPE:
775
ADDRESS:1753 SOUTH MAIN STREETTELEPHONE:
(408) 438-0442
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:75CENSUS: DATE:
12/19/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator, Melissa RamosTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek client timely medical attention.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA met with Administrator (ADM) Melissa Ramos and stated the purpose of the visit.

On 10/6/2023, the Department received a complaint with the above allegations. On 10/12/2023, the Department conducted the initial investigation.

On 10/4/2023 at approximately 12:00pm, client C1 sustained an injury as a result of a witnessed fall at the facility. Per Incident Report from facility, client C1 had a fall wherein staff were able to assist and protect C1 from not hitting his/her head on the ground. Staff assisted C1 to a chair and facility staff applied ice on injured left foot. The transportation van was ready to take clients back to the resident facilities and C1 was transported back to his/her residential facility.

Continuation on LIC 9099-C, Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
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 5
Control Number 26-AS-20231006134901
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: 12/19/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2 of 2.
On 10/12/2023, the Department conducted an initial investigation visit to the facility. LPAs conducted interviews with 5 staff members, including ADM. 4 Out of 5 staff members stated C1 was injured and had symptoms of swelling on the left ankle in the facility’s transportation van, driving from the facility to C1’s residential facility.

Based on interview with S4, C1 noticed the swelling of the left ankle and C1 removed both shoes and socks as a result of the swelling. Once C1 reached the residential facility, C1 needed 2-person assistance to get out of the transportation van. The residential facility staff brought out an office chair with wheels to transport C1 from the van into the residential facility and eventually C1 was taken to the hospital, where C1 was evaluated to have sustained a fracture due to the fall.

Based on interview with ADM, ADM stated “[he/she] should have taken [C1] to the ER or Urgent Room” and in the future, ADM “will bring the resident to the conference room and provide first aid. If the resident needs medical attention, they will call 911 and call the parents or the Home Administrator.”

Based on record review of the Daily Progress Report for R1 for 10/4/2023, notes stated C1 “fell to the floor…twisting [the] left foot”. The report did not mention any first aid initiated and initiation of seeking timely medical attention. Based on text messages between Home Administrator and Facility Representative (FR), FR stated C1 is having a little bit of trouble in regards to client walking on his/her own.

Based on record review of the Program Plan, under Emergencies and First Aid, if there is an urgent medical condition, such as a physical change which may be swelling, the staff to contact facility program director or licensee and staff to call for medical advice. The Program Plan states for staff to call 911 for emergencies after first aid is applied to client.

Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.
Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator and a copy of the report was provided. Appeal Rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20231006134901
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2023
Section Cited
CCR
82075(a)
1
2
3
4
5
6
7
82075 Health-Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for
and/or provision of transportation to the nearest available services.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator stated to submit a plan of action understanding regulation and provide staff training by POC due date. Licensee/Administrator agreed and understood.
8
9
10
11
12
13
14
Based on record review and interviews, facility did not ensure C1 received the necessary first aid and other needed medical servies which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5