<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202578
Report Date: 05/21/2024
Date Signed: 05/22/2024 08:13:18 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/26/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20230926161818
FACILITY NAME:CEDAR MANOR LLCFACILITY NUMBER:
435202578
ADMINISTRATOR:CASIM, ELVIRAFACILITY TYPE:
735
ADDRESS:415 HEATH STREETTELEPHONE:
(408) 945-9197
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:6CENSUS: 5DATE:
05/21/2024
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Ronaldo RapisuraTIME COMPLETED:
04:26 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of supervision for residents and caused a resident was assaulted by another resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Steve Chang and Manuel Monter conducted an unannounced investigation visit to deliver the investigation findings and met with House Manager (HM) Ronaldo Rapisura.

On 09/26/2023, the Department received a complaint with the allegation that Lack of supervision for residents and caused a resident was assaulted by another resident.

On 10/05/2023, an unannounced initial investigation visit was conducted, LPAs interviewed ADM, House Manager (HM) and two staff (S1, S2) and 3 residents (R1 - R3).

LPA requested roster of clients, LIC500, staff schedule, resident Appraisal Needs Service Plan, and incident reports.

Continuing on LIC9099-C. Page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/26/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20230926161818

FACILITY NAME:CEDAR MANOR LLCFACILITY NUMBER:
435202578
ADMINISTRATOR:CASIM, ELVIRAFACILITY TYPE:
735
ADDRESS:415 HEATH STREETTELEPHONE:
(408) 945-9197
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:6CENSUS: 5DATE:
05/21/2024
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Ronaldo RapisuraTIME COMPLETED:
04:26 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not providing adequate food portions for the resident.
Resident's soiled clothing was left in backpack for multiple weeks.
Facility is not meeting resident's needs leaving resident in feces.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Steve Chang and Manuel Monter conducted an unannounced investigation visit to deliver the investigation findings and met with Administrator (ADM) Elvira Casim.

On 09/26/2023, the Department received a complaint with the above allegations.

On 10/05/2023, an unannounced initial investigation visit was conducted, LPAs interviewed ADM, House Manager (HM) and two staff (S1, S2) and 3 residents (R1 - R3).

LPA obtained roster of clients, LIC500, staff schedule, resident Appraisal Needs Service Plan, and incident reports.

Continuing on LIC9099-C. Page 1 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20230926161818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: CEDAR MANOR LLC
FACILITY NUMBER: 435202578
VISIT DATE: 05/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility is not providing adequate food portions for the resident:
On 10/05/2023, LPA interviewed Administrator (ADM). ADM stated he/she goes to grocery shopping at least once every week. ADM stated the facility food supplies should be no problem.

LPA interviewed House manager (HM). HM stated the facility prepares resident R1's lunches every Monday and Tuesday for R1's stay in the day program, R1's family member prepares R1's lunches every Wednesday and Thursday for R1's stay in the day program, and the day program prepares R1's lunches every Friday. HM stated the facility staff put R1's lunch box and clean clothes in R1's backpack for R1 to go to day program.

LPA observed staff provided snack to R1 after R1 returning from day program to the facility. S1 showed LPA R1's dedicated lunch box. LPA observed R1's lunch box is big enough for an adult if the food is filled up the lunch box, and R1's schedule for day program is 9:00AM to 3:00PM Monday to Friday.

Based on the observation and interviews, no evidence to indicate that the facility is not providing adequate food portions for the resident.

Resident's soiled clothing was left in backpack for multiple weeks:
On 10/05/2023, LPA interviewed House Manger (HM). HM stated the facility prepare clean clothes, clean diaper and lunch box in R1's backpack every day before he/she goes to the day program. HM stated R1 needs to check every 2 hours for diaper. HM stated the day program staff should change R1's diaper and clothes from R1's backpack if needed. HM stated the day program staff will throw R1's soiled diaper away, and will put R1's soiled clothes in a plastic bag and attached to R1's backpack. HM stated the facility staff check R1 and clean R1 when R1 returning from day program. HM stated if staff find R1's backpack with soiled clothes, the staff will laundry the clothes and put the clean clothes in the backpack. HM stated if the facility staff do not find the soiled clothes with R1's backpack, then the staff will change the clothes every two weeks.

LPA observed S1 changed R1's diaper and clothes, cleaned R1, and laundered R1's soiled clothes.
Based on the interviews and observation, no evidence to indicate that the resident's soiled clothing was left in backpack for multiple weeks.
Continue on LIC9099-C. Page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20230926161818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: CEDAR MANOR LLC
FACILITY NUMBER: 435202578
VISIT DATE: 05/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility is not meeting resident's needs leaving resident in feces:

On 10/05/2022, LPA interviewed House Manger HM. HM stated the facility staff put the clean clothes, sufficient clean diapers and lunch box in R1's backpack ever morning before R1 goes to the day program. HM stated the facility staff change R1's diaper every morning before he/she goes to day program. HM stated the vehicle transports R1 to the day program also taking other clients from other facilities. HM stated the transportation time may take around 25 minutes. HM stated he/she was unable to guarantee that R1 arrives at the facility always with clean diaper. HM stated he/she is sure that R1 leaves the facility with clean diaper.

HM stated the facility communicated with day program before that the facility prepares sufficient diapers in R1's backpack and the day program staff check R1's diaper every two hours. HM stated the facility prepares sufficient diapers in R1's backpack for R1 to change in the day program.

LPA interviewed staff S1 and S2. Both confirmed what HM stated that the staff change resident's diaper before residents go to day program.

Based on the interviews, there is no evidence to indicate that the facility staff left resident with feces.

The Department has investigated the above allegation. Based on interviews, the department has found the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid, there is not a preponderance of evidence to show the alleged violations did or did not occur.

No citation noted today. Exit interview was conducted with HM. This report was provided to HM for signature. A copy of the report was provided to HM.

Page 3 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 26-AS-20230926161818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: CEDAR MANOR LLC
FACILITY NUMBER: 435202578
VISIT DATE: 05/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Lack of supervision for residents and caused a resident was assaulted by another resident:
On 9/25/2023, client (R1) was found a big bruise on his/her left side of the face and his/her left ear turned a dark shade of purple in the day program. On 9/27/2023, the Department interviewed the Program Director (PD). PD stated this is not the first incident for R1, but this time is serious. PD stated the day program did not report to CCL office for the prior incidents.

On 10/05/2023, LPA interviewed Administrator (ADM), and House Manager (HM). ADM stated he/she did not receive a report for the incident from the facility staff until he/she received a phone call from the day program. ADM stated he/she interviewed night shift staff (S3), and S3 stated the incident occurred at the bed time around 9:30PM on 9/24/2023. Resident R1 and R2 had physical altercation in the bed room. S3 went to the bedroom to to separate them when S3 heard the noise. S3 evaluated R1 and found it was not serious. S3 did not call 911, did not call ADM, and did not apply first aid to R1. ADM stated the morning shift staff on 9/25/2023, did not find R1 was serious and let R1 went to day program as usual. HM stated he/she did not receive the report for the incident from the night shift staff. HM stated the facility changed R1's roommate as R3 after the incident occurred.

Based on a review of facility incident report, dated September 25, 2023, the altercation between R1 and R2 occurred on September 24, 2023 at 9:30pm

Based on a review of the facility's staffing schedule for September 25, 2023, two staff are listed to be working during the time of the alleged incident, Staff S3 and S5.

On May 21, 2024, LPA interviewed staff S3. S3 stated he/she was giving the residents a bath when R1 and R2 began fighting over an ipad. S3 stated he/she was the only staff member working when the altercation took place.

LPA interview HM. HM acknowledged that there was only 1 staff on duty when the altercation between R1 and R2 took place.

A review of R1's IPP, R1 requires constant supervision during waking hours to prevent injury/harm in all setting and needs to be continuously monitored for physical aggression.

Continue on LIC9099-C. Page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20230926161818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CEDAR MANOR LLC
FACILITY NUMBER: 435202578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2024
Section Cited
CCR
80755(a)
1
2
3
4
5
6
7
80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator stated to submit a plan of correction by POC due date to conduct staff training in ensure care and supervision are provided to residents to prevent alteration/fighting among the residents.
8
9
10
11
12
13
14
Based on the interviews, The facility did not have two staff members working as scheduled resulting in R1 and R2 getting in an altercation, while staff S3 was bathing a resident. This posed an immediate health and safety rsik to resident in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20230926161818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: CEDAR MANOR LLC
FACILITY NUMBER: 435202578
VISIT DATE: 05/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A review of R2's appraisal/Needs and service plan, R2 requires constant supervision during waking hours to prevent injury/harm in all setting. A review of R2's IPP, states R2 can portray behaviors of attempting or engaging in aggressive acts and R2 requires constant supervision during waking hours to prevent injury/harm in all setting.

Based on the interviews, the facility staff were lack of care and supervision to residents, caused residents involved in physical alteration, and led to injuries. The staff did not apply the first aid to the injured resident, nor did notify ADM.

The Department has investigated the above allegation. Based on interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D.

Exit interview conducted with HM. The report was provided to HM for signature. A copy of this report was provided to HM. Appeal Rights was provided.

Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7