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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202503
Report Date: 06/17/2021
Date Signed: 06/18/2021 09:23:27 AM



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
01/26/2021 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20210126091919
FACILITY NAME:HEALTHY LIVING RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202503
ADMINISTRATOR:MADELINE TAM CHOWFACILITY TYPE:
740
ADDRESS:251 DELIA STREETTELEPHONE:
(408) 493-6955
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: DATE:
06/17/2021
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Randel ChowTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident got hit by facility staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted a complaint tele-visit to deliver investigation findings. Due to COVID-19 preventive measures, facility visits have been suspended. LPA met with administrator (ADM) Randel Chow.

On 01/26/2021, the Department received a complaint about the above allegation against the facility. An initial complaint investigation visit was conducted on 01/29/2021. R1 and ADM were interviewed. R1's Physician report, Appraisal Needs and Services Plan, and Functional Capability were obtained . On 01/28/2021, 03/11/2021, LPA interviewed several residents, a family member of resident, a staff, and ADM.

Continued, see LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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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Control Number 26-AS-20210126091919
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: HEALTHY LIVING RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202503
VISIT DATE: 06/17/2021
NARRATIVE
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Resident got hit by facility staff:

On 01/29/2021, LPA interviewed ADM. ADM stated that on 01/20/2021, a law enforcement officer came to facility to respond to a report that a resident (R1) in the facility has been hit by facility staff. ADM stated that R1 was interviewed by law enforcement officer, R1 denied the allegation.

On 01/25/2021, the department received a self reported incident report (LIC624) regarding S3 was hit by R1. According to the report (LIC624), on 01/23/21, staff (S3) found R1's soiled underpants on the floor full with feces. S3 took a picture of the stained floor and soiled underpants to show to R1. R1 then struck S3 on right eye with R1's right fist.

On 01/29/2021, LPA interviewed R1, R1 stated R1 did not tell anyone that R1 was hit by staff. R1 was not able to provide details of incident.

On 3/11/2021, LPA interviewed staff (S3). S3 denied allegation that S3 hit R1. S3 stated S3 did not see or hear any staff hit residents. S3 stated that R1 hit S3 on 01/23/21, but it was not a hard hit. S3 stated it might be possible that S3 and R1 touched each other by accident when S3 changed the diaper for R1, because R1's left side of body is paralyzed.

The department has investigated the above allegations. Based on the investigation, observations, records reviewed, and interviews conducted, the Department found that the
above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with Administrator. A copy of this report was provided via email for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC9099 (FAS) - (06/04)
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