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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202567
Report Date: 07/09/2024
Date Signed: 07/09/2024 11:12:10 AM

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
07/05/2024 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20240705092559
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:
07/09/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Prince-Stanley AmasTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility has a bed bug and cockroach infestation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator Prince-Stanley Amas.

During visit, LPA toured 17 out of 17 bedrooms and the facility kitchen area. LPA observed bed bugs in 6 out of 17 bedrooms. LPA Marrufo observed 3 cockroaches in the facility kitchen area. LPA Marrufo interviewed 13 residents 6 out of 17 interviewed residents stated to have observed bed bugs. 4 out of 17 interviewed residents stated to have observed cockroaches at the facility. LPA Marrufo interviewed Administrator Amas, who stated a contracted pest control company comes to the facility once per month. Administrator Amas stated to spray the facility with bug spray once per week. A deficiency was cited as per California Code of Regulations Title 22. See LIC9099-D for more information. A civil penalty of $250 was assessed for a repeated violtation. See LIC421FC page for more information. This report was reviewed with Administrator Amas and a copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
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 2
Control Number 26-AS-20240705092559
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: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2024
Section Cited
CCR
80087(a)(1)
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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.
(1) The licensee shall take measures to keep the facility free of flies and other insects.
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Licensee agrees to submit a Plan of Correction by POC date to CCL stating how the licensee will increase the measures taken to keep the facility free of flies and other insects, including bed bugs and cockroaches.
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This requirement was not met as evidenced by: Licensee did not ensure that measures were taken to keep the facility free of bed bugs and cockroaches, as evidenced by 6 out of 17 bedrooms containing bed bugs and the facility kitchen area containing 3 cockroaches during visit, which poses an immediate health risk to residents in care. * A civil penalty of $250 was assessed for a repeated violation. *
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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: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2