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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202331
Report Date: 03/14/2024
Date Signed: 03/14/2024 01:48:40 PM

Substantiated


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
03/07/2024 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20240307160533
FACILITY NAME:SVS GILROY ADULT DAY PROGRAMFACILITY NUMBER:
435202331
ADMINISTRATOR:ALISON NOBLEFACILITY TYPE:
775
ADDRESS:7101 MONTEREY ROADTELEPHONE:
(408) 843-9630
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:60CENSUS: DATE:
03/14/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Michelle PagsisihanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are physically abusing client in care.
INVESTIGATION FINDINGS:
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LIcensing Program Analyst (LPA) David Marrufo conducted an unnanounced initial complaint investigation visit and met with Michelle Pagsisihan, Program Director.

During visit, LPA Marrufo obtained copies of written statements by staff S1, S2, and S3, an Incident Report filed by the facility on 03/07/2024, and Employee Separation Form for staff S4 and S5. LPA Marrufo also interviewed staff S1-S3, staff S6, and Program Director Michelle Pagsisihan.

According to the written statements of staff S1-S3 and the Incident Report, and the interviews of staff conducted during visit, there were two incidents of staff physically abusing resident C1 on 03/05/2024. The first incident occurred at approximately 12:00 PM and involved staff S4 slapping C1 on the back and pulling C1 by the back of C1's shirt from the facility music room to the computer room. This incident was witnessed by staff S1 and S2.
See LIC9099-C for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
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-20240307160533
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: SVS GILROY ADULT DAY PROGRAM
FACILITY NUMBER: 435202331
VISIT DATE: 03/14/2024
NARRATIVE
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S4's Employee Separation Form states S4 was separated from the facility as an employee on utilizing a non-approved redirection technique and that other staff observed a slapping sound.

The second incident occurred approximately at 1:15 PM and involved staff S5 putting client C1 in a choke hold by putting an arm around C1's neck and holding one of C1's wrists behind C1's back.

S5's Employment Separation Form states S5 was separated from the facility as an employee for utilizing physical restraint with a resident.

A deficiency was cited as per California Code of Regulations Title 22. See LIC9099-D for more information.

This report was reviewed with Program Director Michelle Pagsisihan and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20240307160533
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: SVS GILROY ADULT DAY PROGRAM
FACILITY NUMBER: 435202331
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2024
Section Cited
CCR
82072(a)(3)
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Personal Rights 82072(a)(3) (a) Each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule,
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Licensee agrees to submit a plan of correction by POC date to ensure that facility staff are provided with in-service training on the personal rights of residents, including the right to be free of corporal or unusual punishment and infliction of pain. Once in-service trainings are completed, the License
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coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication, or aids to physical functioning. This requirement was not met as evidenced by: Licensee did not ensure that staff S4 did not slap and pull C1 by C1's shirt and staff S5 did not put C1 in a chokehold restraint, which poses an immediate safety risk to residents in care.
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shall submit training records to CCL including the names of staff trained, dates of training, training topics, and names and qualifications of trainer(s).
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3