435202428-4-17-2025-26-AS-KHOS-DG7GM8-20250429052729

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202428
Report Date: 04/17/2025
Date Signed: 04/17/2025 02:20:33 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
02/14/2025 and conducted by Evaluator Kiran Jain

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20250214152332

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: 33	DATE:	04/17/2025
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Chidi Ikeme		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not provide care and supervision of resident in care, resulting in burns on resident legs, abdomen and groin

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On April 17, 2025, at 1:35 PM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to deliver the findings of a Complaint Investigation. Upon arrival, the LPA was greeted by the Administrator (ADM), Chidi Ikeme. The LPA disclosed the purpose of the visit.

On 02/14/2025, the Department received a complaint with the allegation that “Facility did not provide care and supervision of resident in care, resulting in burns on resident’s legs, abdomen, and groin.” On 02/18/2025, the initial complaint investigation was conducted at the facility. The following documents for resident (R1) were obtained: 1) Admission Agreement (01/20/2025), 2) Physician's report (Dated: 04/25/2024), 3) Needs and Service Plan (Dated: 04/25/2024), 4) Preplacement Appraisal (Dated: 04/25/2024), 5) Functional Capability Assessment (Dated: 04/25/2024), and 6) Identification and Emergency Information (Dated: 04/25/2024).

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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-20250214152332

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
	VISIT DATE: 04/17/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on the review of medical records from Santa Clara Valley Medical Center, R1 was evaluated by the burn team, who did not feel the skin lesions R1 had were consistent with typical burns.

Dermatology was consulted and they believed that the skin lesions R1 had were likely related to an underlying bacterial infection and intertrigo. Blood tests confirmed the presence of bacterial skin infections, including Group A Streptococcus (GAS) and Pseudomonas.

Infectious Disease was also consulted, and they noted the possibility that R1 presented with GAS-mediated toxic shock syndrome, which can cause widespread erythema and desquamation, potentially explaining the ulceration on R1’s right leg. Staph toxic shock syndrome was considered less likely, as blood cultures grew GAS. The source of the GAS infection remained unclear but may have originated from cellulitis or a leg wound. No retained foreign body was identified. A superficial swab of the leg grew Pseudomonas. Infectious Disease indicated that the GAS infection could have originated from R1’s burns, but it was unlikely to be caused by hot water, as the timing did not align with how such infections typically develop because R1 had sought treatment the same day they allegedly sustained the burn.

Based on the review of R1’s Physician's Report, dated 04/25/2024, R1 was able to care for all personal needs, including bathing and dressing.

Based on the review of R1’s Functional Capability Assessment, dated 04/25/2024, R1 was able to bathe or shower without help, dress independently, and manage their own personal hygiene.

Based on the interview with R1, R1 stated they took a shower by turning on the bathroom faucet and using a bowl to wash themselves for about 20 minutes. R1 said, “I guess the water was hot and I didn’t feel it.” R1 explained there was no one else in the bathroom and that no one assisted them in bathing. On the same day, R1 informed staff that their leg hurt and that they had fallen. The staff then called 911. When asked whether the staff delayed in calling paramedics, R1 responded “No.” R1 did not make any complaints or claims prior to their hospitalization.

Based on an interview with R1’s roommate (RM), RM did not observe any burns, redness, blisters, or skin conditions on R1. RM did not recall hearing R1 complain of pain, did not witness R1 fall, and stated that they did not pay much attention to R1.

Continued on LIC9099-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20250214152332

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
	VISIT DATE: 04/17/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on interviews with three (3) facility staff members (AD, S1, and S2), the water temperature was described as normal. Staff stated that residents had their laundry cleaned weekly and their bedding changed every 15 days. The staff denied observing any burn injuries or skin infections during the week of R1’s incident and confirmed that all clients at the facility, including R1, were independent.

Based on observations, interviews conducted, and records reviewed, the department has determined that the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. Therefore, the allegation is UNSUBSTANTIATED.

No deficiencies were cited under the California Code of Regulations, Title 22.

An exit interview was conducted with the Administrator. A copy of this report was discussed and provided to the Administrator, Chidi Ikeme, whose signature on this form confirms receipt of this report.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3