435202529-4-29-2022-26-AS-KHOS-CEH2UB-20220516174205

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202529
Report Date: 04/28/2022
Date Signed: 04/29/2022 08:03:35 AM

Unfounded

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
09/27/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20210927095201

FACILITY NAME:	MOSELLE CARE HOME		FACILITY NUMBER:	435202529
ADMINISTRATOR:	MOHASSEL, LORI		FACILITY TYPE:	740
ADDRESS:	6797 MOSELLE DRIVE		TELEPHONE:	(408) 960-6279
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95119
CAPACITY:	6	CENSUS: 3	DATE:	04/28/2022
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Zenebesh Ghebresellasie		TIME COMPLETED:	03:22 PM

ALLEGATION(S):

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Resident was sexually assaulted while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint visit to deliver investigation finding. LPA met with Licensee (LNS) Zenebesh Ghebresellasie.

On 09/27/2021, the Department received a complaint of the above allegation. On 09/28/2021, an unannounced complaint inspection visit was conducted. A wellness inspection and a facility tour were conducted. LNS and 1 residents were interviewed.

On 09/30/2021 and 10/04/2021, the Department interviewed alleged victim. The alleged victim family member was interviewed on 9/30/2021.

Continued, see LIC 9099-C, pages 1 of 2

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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-20210927095201

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: MOSELLE CARE HOME	FACILITY NUMBER: 435202529
	VISIT DATE: 04/28/2022

NARRATIVE

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Based on the interviews with alleged victim on 9/30/2021 and 10/04/2021, the alleged victim has not been sexually assaulted or physically abused in facility. The alleged victim stated he/she has not been abused in any way in facility. The alleged victim stated the facility staff and residents treated the resident appropriately and stated he/she feels safe living in facility.

Staff, resident, and family members were interviewed and all denied knowledge of sexual assault by the facility.

A copy of the police report reviewed noted the alleged victim stated he had been physically abused but clarified that no one at the care home was abusing him/her.

The Department has investigated the above allegation. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with LNS. This report was provided to LNS for signature.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC9099 (FAS) - (06/04)

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