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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202567
Report Date: 04/22/2024
Date Signed: 04/22/2024 04:01:48 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: 29DATE:
04/22/2024
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Joyce AmasTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility has pests
INVESTIGATION FINDINGS:
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During tour of 16 resident bedrooms on 11/01/2023, LPA Marrufo did not observe any bed bugs, mice, or spiders in any of the bedrooms. LPA Marrufo observed 2 cockroaches in 1 out of 16 bedrooms. 8 out of 9 interviewed residents stated to have observed pests in resident bedrooms, including bed bugs, mice, cockroaches, and spiders.

During interview on 11/01/2023, Administrator Amas stated to spray the resident bedrooms and hallways once a week with bug spray and a steamer. LPA Marrufo obtained invoices from a pest control company that listed Administrator Amas as the customer and the facility address as the location. The invoices were dated 02/17/2023, 05/02/2023, 08/26/2023, and 10/15/2023. The invoices state the targeted pests were ants, unknown, roaches, spiders in the exterior areas and roaches and live pests were targeted in the bedroom, basement, bathrooms, family room, and kitchen.

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: 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: 1 of 3
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: 04/22/2024
NARRATIVE
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Based on records review, interviews and observations there is preponderance of evidence to prove the alleged violation 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 Joyce Amas and a copy of the report and appeal rights were provided.


Page 2 of 2.



END REPORT
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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: 04/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2024
Section Cited
CCR
80087(a)(1)
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80087(a)(1) 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. (1) The licensee
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Licensee agrees to submit a Plan of Correction to CCL by POC date stating how the licensee shall ensure that the licensee shall take measures to keep the facility free of flies and other insects.
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shall take measures to keep the facility free of flies and other insects. This requirement was not met as evidence by: LPA Marrufo observed 2 cockroaches in 1 out of 16 bedrooms. 8 out of 9 interviewed residents stated to have observed pests in resident bedrooms, including bed bugs, mice, cockroaches, and spiders, 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: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3