435202376-10-22-2021-26-AS-KHOS-C88L5K-20211028082716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202376
Report Date: 10/22/2021
Date Signed: 10/22/2021 04:21:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/16/2021 and conducted by Evaluator Anna Bui

COMPLAINT CONTROL NUMBER: 26-AS-20210616150818

FACILITY NAME:	BONNEVIE RESIDENCE AND CARE		FACILITY NUMBER:	435202376
ADMINISTRATOR:	RAMIRO CUSTODIO		FACILITY TYPE:	740
ADDRESS:	555A MC LAUGHLIN AVENUE		TELEPHONE:	(408) 931-6077
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95116
CAPACITY:	6	CENSUS: 6	DATE:	10/22/2021
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Ramiro Custodio		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility is overcharging resident.

INVESTIGATION FINDINGS:

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On 10/22/2021 at 12:15 pm, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced complaint investigation visit to deliver the finding to the above allegation. LPA met with Ramiro Custodio, Administrator.

On 06/23/2021, an initial 10-day complaint investigation was conducted.

Between 06/23/2021 and 10/20/2021, 2 staff and one of the Licensees were interviewed. 3 out of 3 stated R4 was only charged for damages R4 did while R4 was at the facility. 2 out of 3 stated R4 paid for the damages at a reduced rate than what the estimate initially was.

-Continued, see LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210616150818

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BONNEVIE RESIDENCE AND CARE	FACILITY NUMBER: 435202376
	VISIT DATE: 10/22/2021

NARRATIVE

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On 06/23/2021, 3 residents were interviewed. 3 out of 3 residents stated they have not been overcharged for rent or anything else at the facility. 3 out of 3 residents stated their monthly charges have been the same every month. LPA attempted four times to interview 1 other resident but was unable to because the resident was sleeping or not at the facility at the time of the interview.

A review of the facility records showed the facility has no policy on property damage charges or liability for residents. R4’s record showed that R4 damaged some property while at the facility. A review of the price estimate showed the alleged damages to cost $7065 to fix; however, during the investigation, it was stated the alleged victim did not feel like they did all the damages listed on the price estimate. R4’s record showed that R4 signed a form stating R4 was not forced to comply or make payment for the damages and late rent owed to the facility. R4’s record also showed R4 paid for damages but at a reduced rate of $6200.

The Department has investigated the above allegation. Based on interviews and records reviewed, the Department found the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

No deficiencies were cited during today’s visit.

Exit interview was conducted with Ramiro Custodio, Administrator. This report was reviewed with Ramiro Custodio, Administrator, and a copy was provided through email for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC9099 (FAS) - (06/04)

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