435202242-5-9-2023-26-AS-KHOS-CSBNZA-20230530105400

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202242
Report Date: 05/09/2023
Date Signed: 05/09/2023 03:39:20 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
04/04/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20230404111425

FACILITY NAME:	EASTER HOME		FACILITY NUMBER:	435202242
ADMINISTRATOR:	FLAMINGO R. LIGUTOM		FACILITY TYPE:	735
ADDRESS:	400 EASTER AVE.		TELEPHONE:	(408) 263-8133
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	6	CENSUS: 5	DATE:	05/09/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Flamingo Ligutom		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff caused injury to resident.
Staff confiscated resident's meal.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator (ADM) Flamingo Ligutom. The Department received the complaint on 04/04/2023 and LPA Marrufo conducted a complaint visit on 04/11/2023.

During the investigation, LPA Marrufo conducted interviews with residents R1-R3, staff S1-S2, and ADM. LPA Marrufo obtained copies of R1-R5’s Physician Reports, Individual Program Plans (IPPs), and Identification and Emergency Contact Information forms. LPA Marrufo conducted a telephone interview with R1’s Conservator (C1) on 04/14/2023.

R1’s IPP states that “[R1] speach uses 3-4 word phrases/sentences. [R1] sometimes echoes back what is said to [R1] in conversation.”

See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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 3

Control Number 26-AS-20230404111425

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: EASTER HOME	FACILITY NUMBER: 435202242
	VISIT DATE: 05/09/2023

NARRATIVE

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R1’s IPP states that R1 prior to having a medication change, R1 used to have a maladaptive behavior of banging R1’s head. R1’s Ongoing Progress Notes state that on 03/29/2023 at 6:30 AM “[R1] bump his head in the kitchen wall without reason. Affected area applied with ice pack and triple antibiotic.” The entry at 5:30 PM the same day states “When we called [R1’s] mom on Facetime, [R1’s] mom asking what happened [R1] said ‘I bump my head in the kitchen.” Mom said why? [R1] said [S2] hurt my feeling because I lied to [S2], [S2] got mad. I miss Flamingo.”

The second page of R1’s Emergency Contact Information form, which states it was prepared by ADM, states that “[R1] also loves to eat and does not know when to stop not until redirected.” R1’s Hospital Visit Progress Notes dated 05/06/2020 state that “obesity” is listed as an item under the “Problems List” section. R1’s IPP report from 04/05/2021 states “[R1] has no control over eating food. [R1] eats fast and excessively. [R1] is supervised closely during meals for risk of choking.”

During interviews, R1 stated that S2 yelled at R1 and took R1’s meal away. R1 stated to have hit R1’s head on the kitchen wall.

During interviews, S1 and S2 stated to have never taken R1’s meal away or to have ever yelled at R1. S1 and S2 stated to have never observed any other staff take R1’s meal away or yell at R1. Both S1 and S2 stated to have never caused any injury to R1, including to R1’s head or face, and to have never observed another staff do so either. S2 stated that S1 applied first aid to R1’s head injury when the incident occurred.

During interview, ADM stated to have never hit or caused injury to R1 and to have never observed a staff do so either. ADM stated to have never observed a staff take a meal away from R1. ADM stated that there was one incident in which R1 returned from Day Program with another client’s food in a container. ADM advised R1 to give back the food and the container since they belonged to someone else.

ADM stated that R1 sometimes hits R1’s head on walls and other objects when R1 becomes frustrated or upset. ADM stated that ADM recently took a vacation and R1 was very upset at that time due to missing ADM. ADM stated that the incident in which R1 hit R1’s head against the kitchen wall on 03/29/2023 occurred while ADM was on vacation.

Page 2 of 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20230404111425

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: EASTER HOME	FACILITY NUMBER: 435202242
	VISIT DATE: 05/09/2023

NARRATIVE

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During Interview, C1 stated that facility staff had contacted C1 to report R1 had banged R1’s head on the kitchen wall. C1 stated staff reported that R1 was frustrated because ADM was on vacation and away from the facility. C1 stated that facility staff must manage R1’s meals because R1 will keep eating unless stopped.

Based on information from interviews conducted with staff, residents, and witnesses, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with Administrator Flamingo Ligutom and a copy of this report was provided.

Page 3 of 3. END REPORT.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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