435202293-6-21-2024-26-AS-RMAO-D72VM3-20240710163253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202293
Report Date: 06/21/2024
Date Signed: 06/21/2024 08:44:08 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
11/18/2021 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20211118151550

FACILITY NAME:	KB CARE HOME		FACILITY NUMBER:	435202293
ADMINISTRATOR:	KAITLYN BROWNELL		FACILITY TYPE:	735
ADDRESS:	1948 SEABEE PLACE		TELEPHONE:	(408) 823-6734
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95133
CAPACITY:	6	CENSUS: 4	DATE:	06/21/2024
		UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Lead staff Flordeliza Mamaradlo		TIME COMPLETED:	08:50 AM

ALLEGATION(S):

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Staff did not prevent an altercation between residents
Resident sustained an injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with lead staff S1, Flordeliza Mamaradlo. S1 called ADM. ADM stated S1 could sign on her behalf.

On November 18, 2021, the Department received a complaint alleging a resident sustained an injury while in care & staff did not prevent an altercation between residents.

On October 22, 2021, Local Law Enforcement (LLE) responded to the call of a battery that occurred at the facility. Based on LLE’s investigation, R2 was struck by R1 at approximately 6:30am. LLE made contact with R1 who stated he/she hit R2 because R2 had spit on him/her. R2 had sustained a small laceration on his/her forehead.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

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-20211118151550

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: KB CARE HOME	FACILITY NUMBER: 435202293
	VISIT DATE: 06/21/2024

NARRATIVE

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Based on a review of R1’s behavioral progress notes, dated October 22, 2021, R2 was sitting in the couch in the living room and R1 was also sitting on the other side of the living room. Staff went to R2’s room to get a jacket, the staff heard R2 screaming. Staff then went to investigate and saw R2 with blood on his/her face.
Based on a review of a facility Special Incident Report dated October 22, 2021, states, R1 hit R2. R1 was claiming R2 spit on him/her. Staff stated they did not observe R2 spit on R1. The report also states the following “R1 is very sneaky and times it just right that when he/she sees the staff getting busy or assisting another staff who is helping another resident, that is the time when R1 hit R2 in the head, splitting his/her eyebrow.”

On February 21, 2024, LPA Monter interviewed 4 residents (R3-R6.) R2 stated he/she did not witness when R1 hit R2 on October 22, 2021. R2 stated the staff does intervene when R1 tried to hurt them. R3 stated that R1 once knocked out a staff while they were trying to protect them. Residents R4 and R5 did not responded to LPA’s questions due to developmental disability. Resident R6 stated he/she did not want to be interviewed.

On May 14, 2024, LPA Monter interviewed staff S1-S4. All staff interviewed stated they were trained regarding R1’s behaviors. 4 Out of 4 staff interviewed stated R1 would try to hit the residents and staff. S3 and S4 stated R1 was difficult to prompt because he/she would ignore staff and try to hit residents because he/she wants to move back home. 4 Out of 4 Staff interviewed (S1-S4) stated they don’t remember what had occurred on October 22, 2021. S1 and S3 stated they remember staff contacting 911, because R2 was struck. S2 stated S2 stated he/she thinks he/she wasn’t working that day, but is having trouble remembering. S4 stated he/she doesn’t remember clearly what had occurred, but does remember staff was present, and separated R1 and R2, then 911 was called.

Based on a review R1’s Individual Program Plan (IPP), dated December 4, 2019, and R1’s Appraisal/Needs and Services Plan (ANS), dated August 7, 2021, R1 is reported to be verbally aggressive at home and at school, and has become physically aggressive with his/her family. R1 is reported to display maladaptive behaviors such as verbal aggression, physical aggression, lying, stealing and property destruction. Both the IPP and ANS state R1 does not have 1:1 staffing.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20211118151550

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: KB CARE HOME	FACILITY NUMBER: 435202293
	VISIT DATE: 06/21/2024

NARRATIVE

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Based on a review of Resident R1’s Records, R1 has had multiple incidents of hitting residents and staff at the facility. The following dates are documented times R1 stuck the other residents and staff at the care home before October 22, 2021; September 15 and 26, 2021, October 9, 10, and 11, 2021. Based on the review of previous incidents, staff were present and have intervened.

Based on a review of all evidence gathered during the investigation, residents R1 and R2 did not engaged in back-and-forth altercation. Only Resident R1 had struck resident R2. Based on interviews and records reviewed, staff were present and responded when R1 stuck R2.

Based on investigation, records reviewed, and interviews conducted, 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.

END OF REPORT.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

LIC9099 (FAS) - (06/04)

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