435202301-10-20-2025-26-AS-CKAI-DQ4V44-20260107150544

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202301
Report Date: 10/20/2025
Date Signed: 10/20/2025 04:27:18 PM

Unfounded

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
10/16/2025 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20251016085414

FACILITY NAME:	PALM VILLAS, CAMPBELL		FACILITY NUMBER:	435202301
ADMINISTRATOR:	SNEPER, GARRY		FACILITY TYPE:	740
ADDRESS:	3333 SOUTH BASCOM AVENUE		TELEPHONE:	(408) 559-8301
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	48	CENSUS: 38	DATE:	10/20/2025
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Community Director Michelle White		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility neglected resident in care.
Facility staff did not provide resident with activities.
Facility staff did not safeguard residents personal belongings.
Facility staff are not meeting residents dietary needs.

INVESTIGATION FINDINGS:

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Licensing Program (LPA) Marcella Tarin arrived unannounced to conduct an initial complaint investigation visit. LPA met with Community Director (CM) Michelle White.

On 10/16/2025 the Department received a complaint with the above allegations.

On 10/20/2025 LPA Tarin interviewed Reporting Party (RP). RP alleges the facility ‘seems to not care” for R1 and all facility staff were ‘fake.’ RP did not provide additional information regarding the above allegations.

On 10/20/2025 LPA Tarin interviewed 3 Staff (S1 to S3) and 5 Residents (R1 to R5). 3 Out of 3 staff R1 is receiving care based on his/her care plan.

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025

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-20251016085414

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: PALM VILLAS, CAMPBELL	FACILITY NUMBER: 435202301
	VISIT DATE: 10/20/2025

NARRATIVE

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3 out of 3 staff state R1 is receiving palliative care and receives palliative care five 5 days a week.

LPA interviewed 5 residents (R1 to R5). 4 Out of 5 residents did not provide information due to neurocognitive disorder. R5 states the staff are taking great care of him/her and has no issues with the care he/she is receiving.

LPA reviewed R1’s physician’s report dated 6/1/2025, which states R1 has neurocognitive disorder and is receiving palliative care.

LPA reviewed R1's care plan dated 8/7/2025, which states R1 is Max assist with bathing, dressing, grooming, dental, transfer and mobility, and cognitive.

LPA reviewed R1's comprehensive palliative care plan dated 10/9/2025, which states R1 is receiving treatment from skilled nurses, palliative aides, and palliative volunteers since 10/11/2025.

Facility staff did not provide resident with activities.
On 10/20/2025 LPA Tarin interviewed 3 Staff (S1 to S3) and 5 Residents (R1 to R5). 3 Out of 3 staff R1 is being provided activities in his/her room due to ambulatory status. S3 states palliative care volunteers visit with R1 twice a month and provide R1 with activities such as music therapy and pet therapy.

LPA interviewed 5 residents (R1 to R5). 4 Out of 5 residents did not provide information due to neurocognitive disorder. R5 states he/she participates in the facility activities, but did not recall the specific activities.

LPA reviewed the facility's October 2025 activities calendar to included art activities such as art appreciation and physical movement activities.

Facility staff did not safeguard residents personal belongings.
On 10/20/2025 LPA Tarin interviewed 3 Staff (S1 to S3) and 5 Residents (R1 to R5). 3 Out of 3 staff R1 has not had of his/her personal belongings go missing.
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SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20251016085414

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: PALM VILLAS, CAMPBELL	FACILITY NUMBER: 435202301
	VISIT DATE: 10/20/2025

NARRATIVE

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LPA interviewed 5 residents (R1 to R5). 4 Out of 5 residents did not provide information due to neurocognitive disorder. R5 states he/she has not had any of his/her personal belongings go missing.

LPA reviewed R1's safeguard for personal property and valuables, which was declined (no items listed) by R1 upon move-in on 9/8/2020.

LPA reviewed incident reports for R1 and did not observe reports for missing personal belongings.

Facility staff are not meeting residents dietary needs.
On 10/20/2025 LPA Tarin interviewed 3 Staff (S1 to S3) and 5 Residents (R1 to R5). 3 Out of 3 staff R1 has a thin/liquids diet, which is provided to R1 by facility staff. S3 states R1 is on a thin/liquids diet as part of R1's care plan.

LPA interviewed 5 residents (R1 to R5). 4 Out of 5 residents did not provide information due to neurocognitive disorder. R5 states he/she is provided 'healthy' meals by the facility and enjoys the food.

LPA reviewed R1’s physician’s report dated 6/1/2025, which states R1 has a modified diet consisting of thin liquids, which is being provided by facility staff.

LPA reviewed R1's service plan dated 8/7/2025, which states for 'Meals and Nutrition' R1 needs 'Max assistance' with a soft/thin liquids diet provided by facility staff daily.

This agency has investigated the complaint alleging the facility neglected resident in care, facility staff did not provide resident with activities, facility staff did not safeguard residents personal belongings, facility staff are not meeting residents dietary needs. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.

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END OF REPORT.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025

LIC9099 (FAS) - (06/04)

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