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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202331
Report Date: 01/06/2025
Date Signed: 01/06/2025 11:11:20 AM

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
10/31/2024 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20241031144640
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: 33DATE:
01/06/2025
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Michele PagsisihanTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility staff failed to provide care and supervision, resulting in resident sustaining a fracture
Faciliy staff did not seek timely medical attention
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Christine Dolores and Marcela Yanez arrived unannounced to deliver the findings for the above allegations. LPAs met with Program Director, Michele Pagsisihan and Regional Director, Daniela Verar.

On 10/31/2024, the Department received the complaint. On 11/01/2024, the initial complaint investigation was conducted.

It was alleged that staff failed to provide care and supervision, resulting in client (C1) sustaining a fracture.

On 10/29/2024, C1 arrived home from day program where C1’s home staff noticed C1 was crying, had scrapes on R1’s forehead and right hand was bleeding. It was found that the day program staff left the side doors of the van open, and C1 fell out of the van while staff were dropping off another client at a different location. Page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
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 4
Control Number 26-AS-20241031144640
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: 01/06/2025
NARRATIVE
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Based on staff interview, the (2) staff who were part of the incident both admitted that on 10/29/2024, they left the side doors of the van open while they were dropping off other clients at a different location, when C1 fell out of the van. 2 out of 2 staff admitted that the side doors of the van should have not been left open. Based on staff interview, it was stated that the (2) staff members “cut corners” and violated several day program policies including not tying R1’s wheelchair down. On 11/06/2024, 2 out of 2 staff were terminated.

Based on review of C1’s medical records, C1 suffered fractures to his/her arm after falling out of the day program’s transportation van.

It was also alleged that staff did not seek timely medical attention for C1, after C1 fell out of the day program’s transportation van. It was alleged that the day program staff did not call 911 and instead, put C1 back in the van and drove C1 home.

It was stated that when C1 arrived home, C1 was crying and had bruising, a scrape on his/her forehead and hands were bleeding.

Based on staff interview, when C1 fell out of the van the 2 staff members picked up C1 where they observed C1 had a scratch on his/her forehead and elbow. Staff transported C1 to his/her home, which according to Google is 0.4 miles away and a two-minute drive from where the incident occurred.

According to the Program Director (PD), 2 out of 2 staff told the PD that C1 had a scratch on his/her arm but did not mention anything about C1 sustaining a scratch on his/her head. The PD did not instruct staff to take C1 to the hospital as 2 out of 2 staff only reported a minor injury which was a scratch on C1’s arm. The PD stated that if his/she had known C1 sustained a head injury, the PD would have instructed staff to call 911.

When C1 arrived at home, C1’s care staff called 911 where it was found that C1 suffered fractures to his/her arm after falling out of the day program’s transportation van.
Page 2 of 3.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20241031144640
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: 01/06/2025
NARRATIVE
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The Department has investigated the above allegations. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegations are substantiated.

An immediate civil penalty of $500 is being assessed against the facility today for a violation in which staff did not provide care and supervision during transportation resulting in C1 sustaining a serious injury. An additional civil penalty will be pending review. See LIC421-IM.

Deficiencies are cited per California Code of Regulations, Title 22. See LIC9099-D.

This report was reviewed with Program Director, Michele Pagsisihan and Regional Director, Daniela Verar and a copy of the report and appeal rights was provided.

Page 3 of 3.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20241031144640
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: 01/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2025
Section Cited
CCR
82078(a)
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(a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement. This requirement is not met as evidenced by:
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Licensee has completed in-service training with staff on 11/25/2024 on the topic of wheelchair training. Licensee will submit this in-service training document and recent in-service training document
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Based on interview, record review, and observation the licensee did not ensure to provide care and supervision during transportation by not following the facility’s safety policy during transport resulting in C1 falling out of the van while on the wheelchair and sustaining a fracture, which poses an immediate health, safety and personal rights risk to persons in care.
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on transporation to LPA Dolores via email by POC due date of 01/07/2025.
Type A
01/07/2025
Section Cited
CCR
82075(a)
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(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.This requirement is not met as evidenced by:
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Licensee will provide in-service training with staff to include special incident reporting and when to seek timely medical attention. Licensee will submit the in-service training document to include the topics
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Based on interview, record review, and observation the licensee did not ensure to provide C1 with needed medical services after C1 fell out of a van and staff observed a scratch on C1’s forehead and elbow which poses an immediate health safety and personal rights risk to persons in care.
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covered, date, duration, and participants to LPA Dolores via email by POC due date of 01/07/2025.
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: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4