<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202429
Report Date: 11/22/2021
Date Signed: 11/23/2021 09:15:01 AM

Unsubstantiated


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
05/25/2021 and conducted by Evaluator Steve Nguyen
COMPLAINT CONTROL NUMBER: 26-AS-20210525114450
FACILITY NAME:A. & T. CARE HOME #3FACILITY NUMBER:
435202429
ADMINISTRATOR:TRAM N. TRUONGFACILITY TYPE:
735
ADDRESS:2495 DASHWOOD AVENUETELEPHONE:
(408) 622-4240
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 6DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Tram TruongTIME COMPLETED:
09:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not providing adequate supervision.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Steve Nguyen conducted an unannounced visit to deliver the complaint investigation finding. LPA met with Administrator (AD) Tram Truong.

On 6/01/2021, Licensing Program Analyst (LPA) Steve Nguyen interviewed reporting party (RP). RP confirmed the allegation and does not have anything further to add.

On 6/03/2021, LPA Marybeth Donovan conducted an unannounced visit at facility to open the complaint for the above allegation. LPA Marybeth Donovan requested the following documents but not limited to: resident file, copies of resident's Individual Program Plan (IPP), appraisal needs and services plan, progress notes, quarterly report, medication administration records and incident reports.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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 2
Control Number 26-AS-20210525114450
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: A. & T. CARE HOME #3
FACILITY NUMBER: 435202429
VISIT DATE: 11/22/2021
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
On 6/03/2021, LPA Marybeth Donovan interviewed 4 Staff. 4 out of 4 staff denied facility staff are not providing adequate supervision.

On 6/03/2021, LPA Marybeth Donovan interviewed 3 residents. All 3 residents answered that they were fine with the home and that they do not have any issues with it. One resident does not have any direct knowledge of the incident. One resident declined to answer any further questions. One resident stated that answering questions may be fine but ended interview right after.

LPA reviewed the following but not limited to documents: resident file and requested copies of resident's Individual Program Plan (IPP), appraisal needs and services plan, progress notes, quarterly report, medication administration records and incident reports. No instances of facility not providing adequate supervision were found.

The Department has investigated the above allegations. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22

Exit interview conducted with Administrator Tram Truong and a copy of this report provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2