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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202331
Report Date: 05/22/2024
Date Signed: 05/22/2024 12:33:33 PM

Document Has Been Signed on 05/22/2024 12:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 PROGRAMFACILITY NUMBER:
435202331
ADMINISTRATOR/
DIRECTOR:		ALISON NOBLEFACILITY TYPE:
775
ADDRESS:7101 MONTEREY ROADTELEPHONE:
(408) 843-9630
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 60CENSUS: 43DATE:
05/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Michele PagsisihanTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with Program Director (PD), Michele Pagsisihan.

The purpose of the visit is to follow-up with an SOC341 the Department received on 05/16/2024. It was reported that on 05/15/2024, staff noticed that a client had not been eating his/her food because normally the client's clothes would be dirty after a meal. The client's lunch was found inside the trash can.

Based on interview, staff (S1) willfully threw away a client's lunch in the trash can. When another staff asked S1 if the client had eaten his/her lunch, the staff lied stating the client was finished eating lunch and was now eating his/her bowl of fruits. This client is non-verbal. The staff did not believe the client had finished his/her food because the client is normally messy after a meal, but the client was observed to be clean. Staff searched for the client's food and found the client's food inside a plastic bag in the trash can. After the observation, another staff had made the client another meal, which the client quickly ate. S1 was questioned after the incident, which S1 did not provide an explanation to why he/she made that decision. S1 apologized and knew it was wrong. S1 resigned that same day.

During today's visit, LPA interviewed 5 staff members (S1 - S5) and provided 5 out of 5 staff a declaration (LIC855). LPA provided her business card for staff who were unable to hand the declaration to LPA Dolores during visit. Documents were obtained to include S1's ID and application, and training document from 05/16/2024.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Program Director, Michele Pagsisihan and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2024 12:33 PM - It Cannot Be Edited


Created By: Christine Dolores On 05/22/2024 at 12:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2024
Section Cited
CCR
82072(a)(3)

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(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, 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 is not met as evidenced by:
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Licensee has corrected the deficiency before visit. Licensee has conducted staff training on 05/16/2024 regarding client's rights. The staff (S1) has resigned and is no longer employed at the day program.
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Based on interview, record review, and observation a client's personal rights was violated by staff (S1) who willfully threw away a client's lunch in the trash can which poses/posed an immediate health, safety, and personal rights risk to persons in care.
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LPA obtained the training record.

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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.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
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