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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202440
Report Date: 03/24/2026
Date Signed: 03/24/2026 04:56:36 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
07/29/2025 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20250729115318
FACILITY NAME:BLUE RIDGE RCHFACILITY NUMBER:
435202440
ADMINISTRATOR:FREDRICKA SAFARFACILITY TYPE:
735
ADDRESS:4209 BRIARGLEN DRIVETELEPHONE:
(415) 385-8900
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 6DATE:
03/24/2026
UNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Administrator, Fredricka SafarTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff physically restrained a resident resulting in a broken arm.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator and stated the purpose of today’s visit.

On 7/29/2025, the Department received a complaint with the above allegations. On 8/5/2025, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
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-20250729115318
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: BLUE RIDGE RCH
FACILITY NUMBER: 435202440
VISIT DATE: 03/24/2026
NARRATIVE
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Page 2 of 3.
It was alleged an incident occurred between 2/23/2018-2/26/2018 where staff (S1) restrained resident (R1) which resulted in R1 sustaining a broken arm.

On 8/5/2025, the Department interviewed Administrator (ADM1) Sashi Kumar. ADM1 stated the facility has new staff that were not working at the facility during the time of time frame of 2/23/2018-2/26/2018 including herself.

On 8/18/2025, the Department interviewed Administrator (ADM2) Fredricka Safar. ADM2 stated they no longer had the files for resident (R1) due to R1 moving out of the facility on 07/21/2025. ADM2 stated on 2/22/2018, R1 slipped and fell on the floor of the facility which resulted R1 hitting the arm on the floor. ADM2 stated she took R1 to the ER and R1’s responsible party was present at the ER. ADM2 stated the facility staff, including S1 did not restrain the resident and there was no physical altercation with other residents or staff.

Based on review of Special Incident Report dated 2/23/2018, on 2/22/2018, R1 got up without holding the walker and fell down on the hardwood floor. Per report, ADM2, Staff S2 and Staff S3 were present at the facility during the incident. Per report, ADM2 checked R1’s body and observed no bruises but R1 was stated R1’s hand was hurting. Facility staff took R1 to the Emergency Room where he was diagnosed with a fracture. Per report, R1 was to wear a cast for 1 week.

Based on review of Day program notes from 2/23/20218 and 2/26/20218, R1’s pictures were attached with report which show R1 wearing a cast and R1 sustaining bruises on the forearm.

Based on review of hospital notes from 2/22/20218 through 3/1/20218, R1 was presented at the Emergency Room with increasing swelling and bruising related to a fall on right shoulder and R1 was placed in a shoulder brace. The notes do not mention the hospital staff having any concerns of foul play or abuse related to resident’s fall on 2/22/2018.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20250729115318
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: BLUE RIDGE RCH
FACILITY NUMBER: 435202440
VISIT DATE: 03/24/2026
NARRATIVE
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Page 3 of 3.

During this investigation, LPA Rai reached out to Staff S1, Staff S2 and Staff S3 multiple times but was not successful in communicating to obtain information regarding the incident which occurred on 02/22/2018.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3