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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202428
Report Date: 05/16/2022
Date Signed: 05/16/2022 03:07:37 PM

Substantiated


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
05/11/2022 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20220511142554
FACILITY NAME:STONE HAVEN CAREFACILITY NUMBER:
435202428
ADMINISTRATOR:CHIDI IKEMEFACILITY TYPE:
735
ADDRESS:578 N. MATHILDA AVE.TELEPHONE:
(408) 481-9920
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY:33CENSUS: 31DATE:
05/16/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Chidi IkemeTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility refused to reaccept COVID-19 positive resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unnannounced initial complaint investigation visit and met with Administrator Chidi "Goddy" Ikeme.

During visit, LPA Marrufo reviewed R1's resident record, including R1's Admission Agreement and Physician's Report. R1's Admission Agreement did not state anything about when the resident is not allowed back into the facility due to illness. LPA Marrufo interviewed Administrator Ikeme. During interview, Administrator Ikeme stated that when he became aware that R1 was positive with COVID, the Administrator had not prepared a COVID quarantine room at that time, so that is why he did not permit R1 back into the facility and had R1's case manager find R1 a hotel room to quarantine in instead.

See LIC9099-C for more information. Page 1 of 2.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
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-20220511142554
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: STONE HAVEN CARE
FACILITY NUMBER: 435202428
VISIT DATE: 05/16/2022
NARRATIVE
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LPA Marrufo reviewed the facility files and observed that Administrator has not submitted an LIC808 Mitigation Plan to the Department.

During visit, LPA Marrufo toured the facility and observed that there was a quarantine room set up at the facility. Staff S1 and Administrator stated that the room was put in place for two other residents who had become positive with COVID after R1 had become positive. The facility also had a bathroom for COVID positive residents only.

An Advisory Note was issued. See LIC9102 for more information.

Based on records review, interviews and observations there is preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is substantiated.

See 9099-D for the deficiency cited per the California Code of Regulations, Title 22.

This report was reviewed with Administrator Ikeme and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20220511142554
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: STONE HAVEN CARE
FACILITY NUMBER: 435202428
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2022
Section Cited
CCR
85072(b)(12)
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85072(b)(12) Personal Rights: (b) The licensee shall insure that each client is accorded the following personal rights. (12) To move from the facility in accordance with the terms of the Admission Agreement. This requirement was not met as evidenced by:
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Licensee agrees to submit a plan to review resident personal rights, incuding rights of residents with COVID and the most recent Provider Information Notices on COVID and submit a statement of understanding to CCL by POC date.
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Licensee did not permit resident R1 to return to the faciity due to R1 having COVID, which poses an immediate safety risk to residents in care.
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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.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3