435202301-4-25-2025-26-AS-KHOS-DGLSX4-20250512141519

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202301
Report Date: 04/25/2025
Date Signed: 04/25/2025 05:15:14 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
11/19/2024 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20241119153013

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: 42	DATE:	04/25/2025
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Activities Director Michelle White		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Staff did not intervene in resident on resident altercation resulting in resident being pushed to ground by another resident

INVESTIGATION FINDINGS:

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On 11/19/2024, the Department received a complaint allegation that facility staff did not intervene in resident-to-resident altercation resulting in resident being pushed to ground by another resident on 11/15/2024.

On 11/22/2024 Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter investigated the alleged complaint that occurred on 11/15/2025 wherein staff did not intervene when Resident (referred to as R1) R1 was pushed to the ground by another resident (referred to as R2).

On November 22, 2024 and April 25, 2025, LPAs interviewed 15 staff, S1-S15 regarding the incident on 11/15/2024. 13 Out of 15 staff stated they did not observe the incident. Staff S1 and S11 stated they were in the dining area when the incident between R1 and R2 occurred.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025

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-20241119153013

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: 04/25/2025

NARRATIVE

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S1 states he/she and a Private Caregiver (referred to as PC) were in the dining area. S1 was serving lunch to a resident. S1 states he/she observed R1 touch R2 on the arm and stomach. S1 states he/she then heard R2 tell R1 to not touch him/her. S1 stated when he/she saw/heard this, he/she walked towards both residents.

S1 stated while he/she was walking towards R1 and R2, that is when R1 touched R2 again, and R2 pushed R1 causing R1 to fall to the ground. S1 stated this all happened in less than 10 seconds. During interviews both individuals were busy with clients when then heard R1 and R2 arguing.

Staff S11 stated he/she had just clocked in the day of the incident. S11 stated he/she was in the staff lounge area walking towards the dining room. S11 stated as he/she entered the dining room, S11 stated he/she saw R2 make contact with his/her arm toward R1, and saw R1 fall. S11 described the hand motion as a swiping motion, in R1's direction. S11 stated he/she saw S1 walking in the direction of both R1 and R2. S11 stated S1 was in the middle of the dining area, when the incident occurred.

Residents were in the dining area at approximately 2PM, S1 heard R1 and R2 talking and heard R2 state “Don’t touch me” to R1. According to staff, they heard R1 and R2 briefly exchange conversation.

LPAs interviewed PC on 4/1/2025 and states he/she was in the middle of the dining room on 11/15/2024. PC states that he/she was taking care of his/her resident when he/she observed R1 push R2. PC states that S1 went over to assist R1 when R2 pushed R1 down to the ground.

LPAs interviewed 6 residents, R1-R5. 3 Out of 6 residents stated they did not observe the incident between R1 and R2. 3 Out 6 residents did not respond to questions due to neurocognitive disorder.

LPAs reviewed physician’s reports for R1 and R2. R1’s physician’s report dated 12/3/2024 with a primary diagnosis of neurocognitive disorder, associated with “confusion, and sundowning behavior.” On the other hand, R2’s physician’s report dated 3/15/2023 with a primary diagnosis of neurocognitive disorder, associated with a mental condition of ‘confusion, inappropriate behavior and aggressive behavior.’

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SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20241119153013

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: 04/25/2025

NARRATIVE

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’LPAs reviewed R1 and R2’s appraisal needs and care plans dated 12/11/2023 and 12/27/2023. R1 and R2 have similar behaviors of aggression due to his/her neurocognitive disorder wherein both residents require supervision by staff.

LPAs obtained and reviewed staff daily notes for R1 from 11/19/2024-12/11/2024. R2 had a previous incident documented on 8/16/2024, where R2 had aggressive behavior involving foul language and being physically too close to another resident.

The Department has completed the investigation of the above allegation. Based on interviews conducted and record reviews, the Department has found that the above allegation is UNSUBSTANTIATED. Although the allegation that resident R1 pushed R2 is true, there is not a preponderance of evidence to prove that the allegations did or did not occur.

An exit interview was conducted with Activities Director Michelle White and a copy of the report was provided.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025

LIC9099 (FAS) - (06/04)

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