435202339-10-4-2024-26-AS-RMAO-DAHJWT-20241029072517

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202339
Report Date: 10/03/2024
Date Signed: 10/04/2024 02:02:32 AM

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
04/15/2024 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20240415134707

FACILITY NAME:	SAINT MICHAEL RESIDENTIAL HOME		FACILITY NUMBER:	435202339
ADMINISTRATOR:	AGUILAR, DEBBIE R.		FACILITY TYPE:	740
ADDRESS:	86 CASHEW BLOSSOM DR.		TELEPHONE:	(408) 623-4832
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 5	DATE:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Debbie Aguilar		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident sustained severe burns while in care due to lack of care from staff

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to deliver the complaint investigation findings, met with Administrator (ADM) Debbie Aguilar and stated the purpose of the visit.

On 4/15/2024 The department received a complaint alleging that the resident sustained severe burns while in care due to lack of care from staff.

On 4/17/2024 - LPA Simi Rai conducted the initial investigation. LPA Rai requested and verified the documents received on the initial case management visit on 4/15/2024.

page 1 of 3, see LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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-20240415134707

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: SAINT MICHAEL RESIDENTIAL HOME	FACILITY NUMBER: 435202339
	VISIT DATE: 10/03/2024

NARRATIVE

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On 4/11/2024 the Department received an incident report regarding a resident who (R1) who set toilet paper on fire while in the bathroom, that caused third and fourth degree burns to R1s feet and legs that resulted to R1s demise.

The department conducted interviwe with 2 staff(S1, S2), 4 residents (R2 to R5), 2 responsible parties (RP1, RP2), LIC/ADM, and 2 case managers (CM1 and CM2).

On 4/17/2024 S1 stated he/she heard the fire alarm. When he/she arrived at R1s bedroom S2 was already pulling R1 out of the bathroom and S1 poured water on the wall that caught on fire. S2 stated that residents are regularly checked between chores, and he/she checks "countless of times, even in the middle of the night." LIC/ADM stated he/she did not see any lighter or cigarette near R1s room and does not know how R1 started the fire. LIC/ADM stated when R1 has cigarettes or a lighter, R1 would give those to staff to be put away in a locked drawer. LIC/ADM stated that R1 would listen to staff.

On 4/17/2024 R2 stated that staff treats residents very nicely and sees nothing unsafe at the facility. R3 stated S2 turned off the oxygen tank and took R4 to safety and then dealt with the fire and R1. R4 stated that residents are not allowed to have a lighter but can get a lighter from staff.

On 4/17/2024 RP1 stated he/she has not noticed anything unsafe about the facility. No lighters or fire type products lying around. If someone smokes, they smoke outside.

On 5/1/2024, the department conducted an interview with case manager 1(CM1), who stated that R1 "has a history of lighting things on fire at a different care home, and does not believe that the staff were aware of the previous fire incident."

On 5/1/2024, the department conducted an interview with RP2. RP2 stated that R1 was known to smoke frequently. RP2 stated that R1 was happy at the facility. RP2 stated he/she did not tell LIC/ADM and staff that R1 has prior history of lighting things on fire.

page 2 of 3 see LIC 9099C

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240415134707

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: SAINT MICHAEL RESIDENTIAL HOME	FACILITY NUMBER: 435202339
	VISIT DATE: 10/03/2024

NARRATIVE

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Based on document review, R1 had different case managers. R1 did not express self-harm or suicidal tendencies, no safety issues or access to weapons were identified, no signs of depression and only goes out to smoke cigarettes.

On 7/8/2024 a follow up interview was conducted with LIC/ADM who stated, the doors of resident's room are always open. Residents are checked on frequently as staff move through the house. Staff are able to hear the clients when they call because it is a small house.

On 7/9/2024 a follow up interview was conducted with S2, who stated there is no schedule or documentation of how often they check on residents, they typically check on clients approximately every 30 minutes.

On 7/23/2024, the department interviewed R1s prior case manager (CM2) who stated that he/she is aware that R1 had a history of lighting things on fire. CM2 stated that current facility staff is aware R1 should not have a lighter and assumed staff knew the reason why R1 is not supposed to have a lighter. The facility is strict about allowing R1 to have a lighter.

Based on document review, the report stated, paramedics who responded to the facility didn’t notice anything that did not line up with the incident as reported.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were cited during today's visit based on California Code of Regulations Title 22. An exit interview was conducted with licensee/administrator Debbie Aguilar, and a copy of the report was provided.

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end of report

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

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