435202301-6-19-2025-26-AS-MPAA-DHWTYC-20250623150827

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202301
Report Date: 06/19/2025
Date Signed: 06/19/2025 01:49:20 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
06/13/2025 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20250613095152

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: 43	DATE:	06/19/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Staff Jimena Pulido		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility neglected resident in care causing resident to sustain injuries

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced initial complaint investigation visit and met Staff Jimena Pulido. LPA stated the purpose of the visit.

On 6/13/2025 the Department received a complaint alleging that the facility neglected a resident in care causing resident to sustain injuries. It is alleged the Resident R1 sustained injuries on 6/11/2025.

On 6/19/2025 LPA Tarin reviewed an Incident Report (IR) submitted to the Department for R1 who had an unwitnessed fall on 6/3/2025. The IR states the facility called emergency services and R1 was transported to the hospital. The IR states R1 would be transferred to a Skilled Nursing Facility (SNF).

Page 1 of 2

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

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 2

Control Number 26-AS-20250613095152

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: 06/19/2025

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

LPA interviewed Staff S1. S1 states R1 was taken to the hospital on 6/3/2025 and is still at a SNF.

Based on interview and documentation review, R1's injuries did not occur at the facility as R1 was taken to the hospital on 6/3/2025 and was then transferred to a SNF. As of 6/19/2025, R1 has not returned to the facility.

This agency has investigated the complaint alleging that facility neglected resident in care causing resident to sustain injuries. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Staff Jimena Pulido, and a copy of this report was provided.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2