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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202567
Report Date: 04/11/2025
Date Signed: 05/06/2025 03:50:34 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
04/03/2025 and conducted by Evaluator Marcela Yanez
COMPLAINT CONTROL NUMBER: 26-AS-20250403100714
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: 28DATE:
04/11/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Esther Fatoye Lead Staff TIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Staff does not ensure resident's rooms are clean.
Staff does not ensure facility is free of infestation.
Staff does not ensure facility flooring is in good repair.


INVESTIGATION FINDINGS:
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***This report is being amended due to substantiate the above allegations and to remove allegations***

Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced initial complaint visit and met with Cyril Inneh designated Administrator, and Esther Fatoye, Lead Care Staff. LPA announced the purpose of the visit. ADM was not able to come to faciltiy due to family emergency and was contacted by phone
During visit, LPA toured both facility buildings, including resident bedrooms, hallways, and bathrooms in both buildings. LPA Yanez interviewed staff and residents during visit. LPA Yanez requested copies of facility invoices with pest control companies during visit but ADM was not able to provide them since he is out of town and designated ADM Cyril Inneh had to leave.

During tour LPA observed rodent running in kitchen/dining room area and a dead mouse and rodent droppings in dining area. which poses an immediate health and safety risk for residents in care.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
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 4
Control Number 26-AS-20250403100714
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: 04/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2025
Section Cited
CCR
85088(c)(1)
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85088 Fixtures, Furniture, Equipment and Supplies (c) The licensee shall ensure ... maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).
This requirement was not met as evidenced by:
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ADM stated they will submit a letter of understanding of the regulation and the bedding and mattress will be replaced by the poc date 04/18/25. ADM will email LPA pictures of bedding and mattress by poc date.
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During tour LPA observed a resident bed with ripped sheets and exposed mattress stuffing and in disrepair, in room 6 of building address 68 s 10th st. This poses/posed a potential Health, Safety or Personal Rights risk to persons in care.
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Type B
05/13/2025
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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ADM stated he will send a detail plan of action on how he will ensure the facility shall be clean, safe, sanitary and in good repair at all times. ADM stated his plan of action will address the damage/stains on residents walls and floors, the exit wood steps in building 64
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During tour LPAs observed residents rooms floor/walls with damage. LPAs observed the exit wood steps in building 64 to be loose and sink in when stepped on. This poses/posed a potential Health, Safety or Personal Rights risk to persons in care.
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with the loose steps. ADM stated he will send the written plan of action by POC date, May 13, 2025.
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: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20250403100714
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: 04/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2025
Section Cited
CCR
80076(a)(17)
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80076(a)(17) Food Service. Kitchens, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and free of rodents, and other vermin.
This requirement was not met as evidenced by:
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Administrator stated they will submit a written plan of action describing how the facility can ensure the home is free of pest and of rodents by POC due date 04/12/25.

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Based on observation during visit LPA saw a rodent running around in the dining are and a dead mouse and rodent dropping in a mouse trap accessible to residents in care This poses an immediate health, safety or personal rights risk to persons 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: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 26-AS-20250403100714
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: 04/11/2025
NARRATIVE
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During tour LPA observed bedding of resident in room 6 of building 68 in disrepair and had ripped sheets that were stained and mattress stuffing was coming out of mattress. This poses a potential health and safety risk for resident in care.

on 04/11/25 and 05/06/25 the Department interviewed Residents R1-R14. 9 out of 15 residents (R1,R2,R4-R6, R8, R10, R12, R14) stated the facility cleans their bedrooms daily. R3 stated 3 months ago there was odor in the restrooms. Resident R6,R8,R12) stated they have observed flooring damaged in the facility. Resident R5 he/she has smelled odors in facility bathrooms

Residents R1-R6, R8,R10,R12,R14 stated they have observed mice in the facility. 10 out of 15 residents (R1-R6,R8, R10,R12, R14) stated they have not observed the facility front and backyard in disrepair.
5 out of 15 (R7,R9,R11,R13,R15) stated they declined to be interviewed.

During tour of the facility LPAs observed several rooms with damage floors such as Room 3-6. (photographs taken). Exiting the facility building 64 first floor back exit LPAs stepped on wood deck stairs which was loose and sank in when stepped on/moved back and forth.

On May 6, 2025, LPA's interviewed staff S1-S3. Staff S2 & S3 stated they have seen mice inside the facility. All staff interviewed stated the facility staff clean residents rooms daily. Staff S2 acknowledged the bedroom 4 did have visible damage.

LPA's interviewed ADM. ADM stated the residents go out a lot. ADM stated they don't dust their shows and will make the dust stuck to the floor. ADM stated they try their best to make sure floors are clean. ADM stated he has spoken to the landlord regarding the woobling steps and it will be addressed.

The Department has completed the investigation of the above allegations. Based on observation and interviews the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are cited during today's visit under Title 22 regulation. This report was reviewed with Lead Staff, Esther Fatoye a copy of the signed report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4