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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202428
Report Date: 10/25/2024
Date Signed: 10/25/2024 11:08:47 AM

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
06/27/2022 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220627122422
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: 32DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator - Chidi Ikeme and Staff - Elizabeth EspiqueTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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- Facility staff speak to residents in an inappropriate manner
- Residents are not receiving adequate amounts of food
- Facility food is infested with pests
- Facility refused to reaccept COVID-19 positive resident
- Residents are not being supervised
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 investiation 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. 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)
Page: 1 of 3
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
06/27/2022 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220627122422

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: 32DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator - Chidi Ikeme and Staff - Elizabeth EspiqueTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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- Facility has pests
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 LPA Marrufo made observations of the facility back in July 7, 2022 and observed cockroaches in the ktichen and observed 4 resident rooms that did have bed bugs at the time. As of today's visit the facility has since implemented pest control services with Western Exterminator and HeatRX to address the issues. During today's visit LPA did not observe any pests in the kitchen and no reports of bed bugs reported by clients in care. This allegation is substantiated based on the observations made on July 7, 2022.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.

Report is reviewed with Elizabeth Espique and a copy is provided on this day.
Substantiated
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)
Page: 2 of 3
Control Number 26-AS-20220627122422
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: STONE HAVEN CARE
FACILITY NUMBER: 435202428
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2024
Section Cited
CCR
80072(a)(2)
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80072(a)(2) Personal Rights - (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This regulation has not been met as evidenced by:
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Facility has since contracted with two extermination services, Western Exterminator and HeatRX, to treat the issues at the time. As of today's visit by the Department, no cockroaches were observed in the kitchen and no reports of bed bugs at this time.
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Based on observtions made on July 7, 2022, The Department observed pests present. Cockroaches were observed in the kitchen of the facility and 4 resident rooms were observed to have bed bugs at the time of the Department's visit on July 7, 2022. These observations posed an immediate health and safety risk to clients in care.
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***POC CLEARED ON THIS DAY***

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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: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
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