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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202567
Report Date: 11/01/2023
Date Signed: 11/01/2023 05:30:48 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
10/25/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20231025084559
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: DATE:
11/01/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Prince-Stanley AmasTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced initial complaint investigation visit and met with Prince-Stanley Amas, Administrator.

During visit, LPA Marrufo observed 16 out of 20 resident bedrooms and 3 out of 3 resident bathrooms. LPA Marrufo interviewed residents R1-R9 and Administrator Prince-Stanley Amas.

During tour of 3 out of 3 resident bathrooms, LPA Marrufo observed 3 out of 3 bathrooms had running sinks, showers, and baths with no clogging. 2 out of 3 bathrooms had no clogged toilets. The first-floor toilet had 1 out of 2 toilets clogged during visit.

During interview, 4 out of 9 interviewed residents stated that the facility toilets are sometimes clogged.

See LIC9099-C for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
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-20231025084559
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: 11/01/2023
NARRATIVE
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During interview, Administrator Amas stated that a resident flushed a metallic object into the toilet and clogged the toilet. Administrator Amas stated to have contacted a plumber to replace the toilet.

During visit, LPA Marrufo observed that a plumber installed a replacement toilet and the replacement toilet flushed properly during visit.

Based on interviews and observations, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegation is substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Prince-Stanley Amas and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20231025084559
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: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2023
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:
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Licensee shall submit a plan by POC date to ensure that the toilet in the first-floor bathroom is unclogged. ***Deficiency Corrected During Visit. Plumber replaced toilet during visit. ***
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 Licensee did not ensure that 1 out of 3 resident bathrooms did not have a clogged toilet, which poses an immediate safety risk to residents in care.
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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: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/25/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20231025084559

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: DATE:
11/01/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Prince-Stanley AmasTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Due to lack of adequate supervision, staff allowed residents to smoke illegal drugs in a resident's room.
INVESTIGATION FINDINGS:
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** Amended on 04/22/2024 to remove the allegation "Facility has pests" and to remove information from the report body about that allegation **


See LIC9099-C for more information. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20231025084559
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: 11/01/2023
NARRATIVE
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During tour of 16 resident bedrooms, LPA Marrufo did not observe any drugs or drug-related paraphernalia, such as drug pipes. 3 out of 9 interviewed residents stated to have observed residents using drugs on the facility grounds.

During interview, Administrator Amas stated facility staff conduct rounds every 30-60 minutes every day to check on the residents and ensure that they are not abusing drugs.
LPA Marrufo interviewed staff S1 who stated staff conduct rounds every 30-60 minutes to check on residents and ensure they are not abusing drugs.

LPA Marrufo obtained copies of the Residents Tracking Log from October 2023, which recorded the tracking of residents throughout the house every hour.

Based on information from observations, interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Prince-Stanley Amas and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5