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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202428
Report Date: 09/28/2023
Date Signed: 09/29/2023 10:48:39 AM

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
08/26/2021 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20210826155057
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:
09/28/2023
UNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:CHIDI IKEMETIME COMPLETED:
10:59 AM
ALLEGATION(S):
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Facility did not provide supervision when resident was out in the community.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Administrator (ADM) CHIDI IKEME.

On 8/26/2021, the Department received a complaint with the allegation that Facility did not provide supervision when resident was out in the community.

On 8/27/2021, an initial investigation visit was conducted, one staff was interviewed.

Continue On LIC9099-C. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
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-20210826155057
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: 09/28/2023
NARRATIVE
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Facility did not provide supervision when resident was out in the community:

On 8/27/2021, the Department interviewed staff (S1). S1 stated all the residents went out on their own to buy the things they want or to go doctors. S1 stated from what he/she knew, every residents could leave the facility unassisted.

On 8/30/2021, the Department reviewed the resident files, the Department found 2 suspect residents (R1, R2) according to the reported suspects' information such as pictures, race, gender and age. The Department reviewed R1 and R2 physician reports and Appraisal Needs and Service Plans and found that R1 and R were unable to leave the facility unassisted or to leave the facility only with staff.

Based on the document reviewed and interviews conducted, the facility staff S1 stated all residents were able to leave the facility on their own. R1 and R2 were found unable to leave the facility without supervision of staff.

The Department has investigated the above allegation. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D.

Exit interview conducted with ADM. The report was provided to ADM for signature. A copy of this report was provided to ADM. Appeal Rights was provided.

Page 2 of 2

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20210826155057
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: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2023
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced:
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ADM understood and agreed to submit a Plan of Correction by the POC due date to prevent residents to wander around without staff supervision.
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Based on interviews and documents reviewed, facility residents were observed wandered around the neighborhoods without staff supervision.
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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: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3