435202428-10-25-2024-26-AS-KHOS-DARK4P-20241106063436

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202428
Report Date: 10/25/2024
Date Signed: 10/25/2024 12:55:12 PM

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
11/30/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20231130113738

FACILITY NAME:	STONE HAVEN CARE		FACILITY NUMBER:	435202428
ADMINISTRATOR:	CHIDI IKEME		FACILITY TYPE:	735
ADDRESS:	578 N. MATHILDA AVE.		TELEPHONE:	(408) 481-9920
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94085
CAPACITY:	33	CENSUS: 32	DATE:	10/25/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator - Chidi Ikeme and Staff - Elizabeth Espique		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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- Staff did not prevent clients from being injured by another client in care
- Staff did not report incident to client's authorized representative
- Staff did not prevent client from smoking in the facility

INVESTIGATION FINDINGS:

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On 10/25/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegations received. LPA met with Administrator Chidi Ikeme via telephone, and Staff Elizabeth Espique, and explained the purpose of today's visit.

During the investigation interviews were conducted and observations were made. Based on the interviews conducted, and the information reviewed from those interviews, there is conflicting accounts for what happened between the facility and complainant. Per interviews the client at the time could not recall how he/she received an injury as it happened in his sleep. Staff make facility rounds at night per interview conducted. The facility does not allow smoking in the facility but clients smoke at times against the facility rules. Staff do address the indoor smoking when observed and instruct clients to exit the facility to smoke. Regarding the injury reporting to the authorized representative, staff indicated that neither them or the client knew the origin of the injury and it was observed as a scratch that occurred at some time when the resident was asleep. Staff indicate that they did report to the clients represenative. Based off of interviews, photos, and observations during the investigation, LPA cannot prove or disprove that the allegations took place as described.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Report is reviewed with Elizabeth Espique and a copy is provided on this day.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

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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