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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202567
Report Date: 05/09/2025
Date Signed: 05/09/2025 06:30:10 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
01/07/2025 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20250107103508
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:
05/09/2025
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Prince-Stanley AmasTIME COMPLETED:
06:45 PM
ALLEGATION(S):
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Staff do not ensure facility is kept in clean sanitary conditions
Staff do not ensure facility is kept free of mal odors
Staff do not ensure facility is kept free of insects
Facility lights, floors, and walls are not in good repair
Staff does not ensure comfortable temperatures are maintained for clients in care
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. On 01/07/2025, the department received a complaint with the above allegations. On 01/14/2025, LPA Marrufo conducted an initial complaint investigation visit.

During visit on 01/14/2025, LPA Marrufo toured two out of two buildings that are part of the facility. Building 1 is located at 64 South 10th street and has 12 bedrooms. Building 2 is located at 68 South 10th Street and has four bedrooms.

During visit on 01/14/2025, LPA Marrufo observed slight mal odors in the following bedrooms in Building 1: Rooms 5, 6, 7, and 11. LPA observed strong mal odors in the following bedrooms in Building 1: Rooms 4 and Rooms 9. Room 9 had a strong urine odor. LPA observed a slight mal odor in Room 1 of Building 2. See LIC9099-C page for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
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-20250107103508
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: 05/09/2025
NARRATIVE
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During visit on 01/14/2025, LPA Marrufo obtained copies of Pest Control Invoices dated 08/09/2024 and 11/08/2024. The Pest Control Invoice from 08/09/2024 states the targeted pests were earwigs, German cockroaches, and spiders. The treated areas were the bedrooms, exterior areas, and kitchen. The Pest Control Invoice dated 11/08/2024 states the targeted pests were ants, centipedes, earwigs, pillbugs, Oriental cockroaches, and spiders. The treated areas were the exterior areas.

During visit on 01/14/2025, LPA Marrufo observed two bed bugs in Room 7 of Building 1. LPA Marrufo observed 3 live cockroaches in a cupboard inside the kitchen of Building 1.

During visit on 01/14/2025, LPA Marrufo interviewed Residents R1-R8. R1 and R6 stated to have observed cockroaches and mice at the facility. R3 and R5 stated to have observed insects at the facility. R4 stated to have observed mice in the facility. R7 stated to have observed lice in the facility. R1, R3, R5, R6, and R8 stated to have observed cockroaches at the facility. R2-R8 stated to have observed bed bugs at the facility.

During visit on 01/14/2025, LPA Marrufo toured the facility. LPA observed blemished, scraped, stained, or pealing tiles in the following bedrooms in Building 1: Room 5, Room 3, Room 12, Room 4, Room 7, Room 9, and Room 10. LPA Marrufo observed pealing paint and dirt stains on the following bedroom walls of Building 1: Room 5, Room 3, Room 12, Room 8, Room 4, Room 7, Room 9, and Room 10. LPA Marrufo observed pealing paint and dirt stains on the walls of Rooms 1, 2, 3, and 4 of Building 2.

During visit on 01/14/2025, LPA Marrufo measured the temperatures inside the bedrooms of Building 1 and Building 2. LPA observed that in Building 1, Rooms 2-7 and 9-11 had temperatures ranging from 56.7 F to 63 F. In Building 2, Rooms 1 through 4 had temperatures ranging from 58.6 F to 59.5 F. During interviews, R1-R3 and R5-R8 stated that the facility temperature was too cold. R4 stated that the facility was not too cold.

Based on records review, interviews, and observations there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegations are substantiated. See LIC9099-D pages for deficiencies cited per the California Code of Regulations, Title 22. Three civil penalties of $250 each were assessed for repeat deficiencies. This report was reviewed with Administrator Prince-Stanley Amas and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20250107103508
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: 05/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2025
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: Licensee did not ensure that four out of 12 bedrooms in building 1
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Licensee agrees to submit a Plan of Correction to CCL by POC date stating how the facility will be kept in sanitary conditions, free of mal odors, and have floors and walls that are clean and kept in good repair. Once cleaning and repairs are
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 and 1 bedroom in Building 2 had mal odors and were sanitary, and that at least 6 out of 12 bedrooms in Building 1 and 4 out of 4 bedrooms in Building 2 had floors and walls that were not clean and in good repair, which poses an immediate health and safety risk to residents in care. *A $250 repeat civil penalty was assessed*
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complete, Licensee shall submit photographs of cleaned and repaired floors and walls.
Type A
05/10/2025
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
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Licensee agrees to submit a Plan of Correction by POC date ensuring that Pest Control contractors spray the facility for bed bugs and that bed bugs are included as targeted pests in the Pest Control contractor's treatment.
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measures to keep the facility free of flies and other insects. This requirement was not met as evidenced by: Licensee did not ensure that 1 out of 12 bedrooms in Building 1 did not have bed bugs, which poses an immediate safety risk to residents in care. *A $250 repeat civil penalty was assessed*
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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: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20250107103508
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: 05/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2025
Section Cited
CCR
80088(1)
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80088 Furniture, Fixtures, Equipment, and Supplies (1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). This requirement was not met as
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Licensee agrees to submit a Plan of Correction to CCL by POC date stating how the licensee shall ensure that temperatures in all resident bedrooms are maintained between 68 F and 85 F.
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evidenced by: Licensee did not ensure that 9 out of 12 bedrooms in Building 1 and 4 out of 4 bedrooms in Building 2 had temperatures between 68 F and 85 F degrees, which poses an immediate health risk to residents in care.
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Type A
05/10/2025
Section Cited
CCR
80076(a)(17)
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80076 Food Services (a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and
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Licensee agrees to submit a Plan of Correction to CCL by POC date stating how the licensee will ensure that the facility kitchen is kept free of vermin, including cockroaches.
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measures shall be taken to keep all such areas free of rodents, and other vermin. This requirement was not met as evidenced by: Licensee did not ensure that there were not three cockroaches in one of the cupboards in the facility kitchen, which poses an immediate health and safety risk to residents in care. *A $250 repeat civil penalty was assessed*
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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: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4