435202392-5-7-2026-26-AS-RMAO-DU8PXY-20260519114306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202392
Report Date: 05/07/2026
Date Signed: 05/07/2026 10:36:03 AM

Unfounded

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
04/13/2026 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20260413162742

FACILITY NAME:	EVONNE'S RESIDENTIAL CARE HOME #1		FACILITY NUMBER:	435202392
ADMINISTRATOR:	PHILOMENA AGBONTAEN		FACILITY TYPE:	740
ADDRESS:	2719 PENITENCIA CREEK RD.		TELEPHONE:	(408) 661-5746
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95132
CAPACITY:	7	CENSUS: 6	DATE:	05/07/2026
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Administrator Philomena Agbontaen		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Staff handled residents in a rough manner
Facility staff did not intervene in resident altercation.
Facility staff do not accord residents with dignity and respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Philomena Agbontaen.

On April 13, 2026, the Department received a complaint alleging staff handled residents in a rough manner

On April 21, 2026, Licensing Program Analyst Manuel Monter interviewed residents R2-R7. 6 Out 6 residents (R2-R7 ) stated they have never observed staff handling residents in a rough manner.

On April 21, 2026, Licensing Program Analyst Manuel Monter interviewed Administrator Philomena Agbontaen, referred to as S1 and staff S2. Both staff interviewed (S1 and S2) stated facility staff have never handled residents in a rough manner. Page 1 Out of 5.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

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 5

Control Number 26-AS-20260413162742

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: EVONNE'S RESIDENTIAL CARE HOME #1	FACILITY NUMBER: 435202392
	VISIT DATE: 05/07/2026

NARRATIVE

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On April 21, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W1. W1 stated he/she visits the facility frequently. W1 stated he/she has never observed staff handling residents in a rough manner.

On May 6, 2026, Licensing Program Analyst Manuel Monter interviewed resident R1. R1 stated, facility staff were never rough with him/her. R1 stated he/she never saw the staff being rough when providing care to other residents. R1 stated he/she didn’t see any instance of the staff being rough when providing care.

On May 6, 2026, Licensing Program Analyst Manuel Monter interviewed witness W2. W2 stated he/she didn’t observe any instance where staff where handling residents in a rough manner.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Facility staff did not intervene in resident altercation.

On April 13, 2026, the Department received a complaint alleging Facility staff did not intervene in resident altercation.

On April 21, 2026, Licensing Program Analyst Manuel Monter interviewed residents R2-R7. 6 Out 6 residents (R2-R7 ) stated they are not aware of any resident on resident altercations or incidents where residents throw objects at each other.

Page 2 Out of 5.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20260413162742

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: EVONNE'S RESIDENTIAL CARE HOME #1	FACILITY NUMBER: 435202392
	VISIT DATE: 05/07/2026

NARRATIVE

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On April 21, 2026, Licensing Program Analyst Manuel Monter interviewed Administrator Philomena Agbontaen, referred to as S1 and staff S2. S1 stated there hasn’t been any resident on resident altercations at the facility. S1 stated there was an incident on the last day R1 was at the home. S1 stated on April 3, 2026, around 10:30-11:00pm, she and S2 heard a sound and R1 began making a commotion. S1 stated when she and S2 entered the room, they asked R1 what had happened. R1 stated his/her phone fell. R1 stated he/she was upset with his/her family member. S1 stated resident R2, was laying in his/her bed asleep. S1 stated R1’s phone was on the ground, near the side of R1’s bed, near the foot area. S1 stated R2 does not have a cell phone. S1 stated when she did ask R1 what had happened, R1 started saying racial slurs, saying negative things regarding R2 race, skin color and also began saying racial things about her and S2.

S2 stated on the last night R1 was at the home, around 10:30-11:00pm, he/she and the S1 heard a loud sound, or something falling. S2 stated he/she and the S1 then went to R1 and R2’s room. S2 stated as they approached, they could hear R1 making a commotion yelling. S2 stated they asked R1 what happened, and R1 stated he/she threw his/her “f-ing” phone. R1 stated he/she threw the phone because he/she can and told staff to pick it up. S1 stated the phone was on the ground close to R1’s right foot. S2 stated he/she observed that R2 was asleep, as he/she entered the bedroom.

On April 21, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W1. W1 stated he/she isn’t aware of any resident on resident altercations or instances where residents are throwing objects at each other.

On May 6, 2026, Licensing Program Analyst Manuel Monter interviewed resident R1. R1 stated his/her cell phone had fallen off the bed. R1 stated the S1 came running to room. R1 stated he/she didn’t have any altercations with the other residents. R1 stated he/she didn’t throw his/her phone at another resident. R1 stated no resident threw their phone at him. R1 stated the issue was when he/she dropped his/her phone by accident, it fell and made a loud sound. R1 stated the staff misunderstood.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20260413162742

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: EVONNE'S RESIDENTIAL CARE HOME #1	FACILITY NUMBER: 435202392
	VISIT DATE: 05/07/2026

NARRATIVE

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The Department reviewed R1’s Progress notes dated April 3, 2026. The progress note stated, R1 threw phone across bedroom. S1 came in urgently due to noise. R1 was asked what that sound was since R1 was the only one awake. R1 replied, “ I threw my fucking phone. Go fucking pick it up.” S1 picked up the phone and asked why R1 threw it. R1 responded, “because I can, you work for me. I tell you what to do.”

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Facility staff do not accord residents with dignity and respect

On April 13, 2026, the Department received a complaint alleging Facility staff do not accord residents with dignity and respect

On April 21, 2026, Licensing Program Analyst Manuel Monter interviewed residents R2-R7. 6 Out 6 residents (R2-R7 ) stated the facility staff treat them with respect. 6 Out 6 residents (R2-R7 ) stated they have never observed the staff treat residents in a disrespectful manner.

On April 21, 2026, Licensing Program Analyst Manuel Monter interviewed Administrator Philomena Agbontaen, referred to as S1 and staff S2. Both staff interviewed (S1 and S2) stated facility staff accorded all residents with dignity and respect. Both staff (S1 and S2) stated they have never observed staff not accord residents with dignity and respect.

On April 21, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W1. W1 stated he/she visits the facility frequently. W1 stated he/she has never observed the staff treat residents in a disrespectful manner.

Page 4 Out of 5.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20260413162742

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: EVONNE'S RESIDENTIAL CARE HOME #1	FACILITY NUMBER: 435202392
	VISIT DATE: 05/07/2026

NARRATIVE

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On May 6, 2026, Licensing Program Analyst Manuel Monter interviewed resident R1. R1 stated R1 stated he/she felt disrespected because the staff were not interacting with him/her. R1 stated the staff treated his/her roommate with kindness and attentiveness. R1 stated when his/her phone fell, staff came running in and asking R2 how he/she was. R1 stated staff didn’t look his/her way. LPA attempted multiple times for R1 to explain how the facility staff didn’t treat him/her with dignity or respect. R1 wasn’t answering the question and digressing to how he/she didn’t like his roommate and didn’t believe the S1 was a nurse.

On May 6, 2026, Licensing Program Analyst Manuel Monter interviewed witness W2. W2 stated, when he/she went out to the facility, and saw the residents he/she didn’t see any issues. W2 stated he/she didn’t observe any instance of staff treating residents in a disrespectful manner or with a lack of dignity.

The Department reviewed R1’s Progress notes dated April 3, 2026. The progress note stated, R1 threw phone across bedroom. S1 came in urgently due to noise. R1 was asked what that sound was since R1 was the only one awake. R1 replied, “ I threw my fucking phone. Go fucking pick it up.” S1 picked up the phone and asked why R1 threw it. R1 responded, “because I can, you work for me. I tell you what to do.”

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Page 5 Out of 5. End of Report.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

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