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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202567
Report Date: 11/10/2022
Date Signed: 11/10/2022 04:02:00 PM

Substantiated


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
03/03/2020 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20200303140339
FACILITY NAME:SUCCESS RCF 1FACILITY NUMBER:
435202567
ADMINISTRATOR:AMAS, PRINCE-STANLEYFACILITY TYPE:
735
ADDRESS:64/68 SOUTH 10TH STREETTELEPHONE:
(408) 293-8166
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:32CENSUS: 32DATE:
11/10/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Prince-Stanley AmasTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff caused injury to resident in care
Facility staff physically prevented resident from exiting their room
Facility staff yelled at resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Prince-Stanley Amas, administrator.

On 03/04/2020, LPA Marrufo conducted an initial complaint investigation visit. During visit, LPA interviewed 7 residents including the victim (resident R1) and Administrator. During interview, R1 stated to have experienced an altercation with Administrator which led to Administrator yelling at R1, physically preventing R1 from leaving R1’s room, handling R1 in a rough manner, including pinning R1 onto the floor by placing both knees on R1’s back, and causing injury to R1, including a knee infusion (swelling), bruising on an arm, and having to go to the emergency room due to the injuries. R1 stated to LPA that about two Saturdays prior to interview, R1 and R1’s significant other showed Administrator the new Playstation 4 video game console that R1’s significant other gifted to R1.

See LIC9099-C for more information. Page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
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 5
Control Number 26-AS-20200303140339
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: SUCCESS RCF 1
FACILITY NUMBER: 435202567
VISIT DATE: 11/10/2022
NARRATIVE
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 Per R1, R1 was in R1’s room with Administrator when Administrator began yelling at R1 to return the Playstation 4 because it was too expensive. R1 stated that Administrator stood in the doorway and would not let R1 leave. R1 tried to evade Administrator and Administrator began trying to wrestle the Playstation 4 from R1’s arms. When R1 moved past Administrator and was in front of Administrator’s office, Administrator and another resident, R2, pinned R1 on the ground by placing their knees on R1’s back. R1 stated to have had a knee bend backwards during the struggle, leading to R1’s knee swelling with water. R1 stated to have stood back up and pushed Administrator, and Administrator pushed R1 back down. R1 stated to have gone to Urgent Care and had X-rays done on R1’s chest, which did not show any rib injuries, and had bruising on R1’s arm and suffered a knee infusion.

LPA Marrufo interviewed R2, who confirmed to have assisted Administrator in pinning down R1. Of the remaining 5 residents, 1 out of 5 claimed to have visually witnessed the altercation and 2 out of 5 claimed to have heard it from another room.

LPA Marrufo interviewed Administrator, who denied having observed any facility staff having been involved in any physical altercations with residents or to have prevented a resident from leaving his or her room.

R1’s Case Manager was interviewed and stated that the incident occurred on 02/22/2020. Case manager saw R1 on 02/24/2020 and observed bruising on R1’s elbows and forearms as well as scrapes.

A police report filed for the incident was obtained and reviewed which corroborates that an assault and battery occurred at the facility over a Playstation 4. The police report identifies R1 as the victim and the Administrator as the suspect.

See LIC9099-C for more information. Page 2 of 3.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20200303140339
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: SUCCESS RCF 1
FACILITY NUMBER: 435202567
VISIT DATE: 11/10/2022
NARRATIVE
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Based on records review, interviews, and observations there is preponderance of evidence to prove the alleged violations did occur, therefore the allegations are SUBSTANTIATED.

An immediate civil penalty of $500.00 is being assessed against the facility today for violations resulting in injury to a resident in care. A Civil Penalty in the amount of $10,000.00 for violation Resulting in Serious Bodily Injury is pending review.

A non-compliance conference meeting will be scheduled.

Deficiencies were cited today under the California Code of Regulations, Title 22, Division 6. Please see LIC 9099-D for deficiencies cited.

This report was reviewed with Administrator Prince-Stanley Amas and a copy of this report and appeal rights were provided.


Page 3 of 3.



END REPORT
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20200303140339
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: SUCCESS RCF 1
FACILITY NUMBER: 435202567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/11/2022
Section Cited
CCR
85102(a)(8)
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85102(a)(8) Emergency Intervention Prohibition. Notwithstanding 85100(a), Section 85102 shall apply to all Adult Residential Facilities as follows: (a) The following emergency interventions shall not be used on a client: (8) Any manual restraint technique in which a staff
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Licensee agrees to develop a plan to train administrator and all staff on not using manual restraint on clients. Once training is completed, Licensee agrees to submit copies of training rosters with names of staff trained, name and qualifications of trainer, and date(s) of training to CCL.
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member places pressure on a person's back or places his or her body weight against the person's torso or back;This requirement was not met as evidenced by: Based on interview, facility administrator pinned R1 on the ground with his knees on R1’s back which resulted in R1 sustaining knee infusion and bruising on arm. This poses an immediate risk to the health of the resident in care. $500 civil penalty was assessed.
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Request Denied
Type A
11/11/2022
Section Cited
CCR
80072(a)(3)
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Personal Rights: Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other
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Licensee agrees to develop a plan to train administrator and all staff on respecting the personal rights of residents and submit plan to CCL by POC date. Once training is completed, Licensee agrees to submit copies of training rosters with names of staff trained, name and
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actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not met as evidenced by: Based on interview, Administrator physically prevented R1 from leaving R1’s room which poses an immediate threat to the health and safety of the resident in care.
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qualifications of trainer, and date(s) of training to CCL.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20200303140339
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: SUCCESS RCF 1
FACILITY NUMBER: 435202567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/11/2022
Section Cited
CCR
80072(a)(1)
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80072(a)(1) (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by: Based on interview,
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Licensee agrees to develop a plan to train administrator and all staff on not yelling at clients. Once training is completed, Licensee agrees to submit copies of training rosters with names of staff trained, name and qualifications of trainer, and date(s) of training to CCL.
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Administrator yelled at R1 which poses an immediate threat to the health and safety of the resident in care. The licensee agrees to submit a plan of staff training on personal rights including training on preventing verbal abuse by POC date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5