435202578-5-22-2024-26-AS-KHOS-D6JLK7-20240624084905

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202578
Report Date: 05/21/2024
Date Signed: 05/22/2024 08:09:17 AM

Unsubstantiated

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
06/24/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220624173645

FACILITY NAME:	CEDAR MANOR LLC		FACILITY NUMBER:	435202578
ADMINISTRATOR:	CASIM, ELVIRA		FACILITY TYPE:	735
ADDRESS:	415 HEATH STREET		TELEPHONE:	(408) 945-9197
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	6	CENSUS: 5	DATE:	05/21/2024
		UNANNOUNCED	TIME BEGAN:	02:59 PM
MET WITH:	Ronaldo Rapisura		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident has unexplained injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) steve Chang and Manuel Monter conducted an unannounced investigation visit to deliver the investigation finding and met with House manager (HM) Ronaldo Rapisura.

On 06/24/2022, the Department received a complaint with the allegation that resident has unexpained injuries.

On 06/30/2022, the Department conducted an initial investigation visit. LPA interviewed ADM, staff and residents.

LPA obtained resident physician report, appraisal needs and service plan, progressive reports, and incident reports.

Continue on LIC9099-C. Page 1 of 2.

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: 1 of 2

Control Number 26-AS-20220624173645

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

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Resident has unexplained injuries:

On 6/24/2022, the facility administrator (ADM) sent an incident report to CCL office that on 6/23/2022 around 8:30PM, two residents R1 and R2 had an altercation. R1 took away R2's tablet when R2 was using it. R2 pushed R1 away and took back the tablet. R1 got upset and hit R2. Two staff intervened to separate R1 and R2 and calm them down. R1 and R2 were calm down and slept through the night. The next day both R1 and R2 conducted their normal routine to day program.

On 6/30/2022, LPA interviewed ADM. ADM stated on 6/23/2022 evening, residents R1 and R2 fought to each other. ADM stated two staff separated them immediately. ADM stated R1 and R2 were placed in different bedrooms after the incident.

LPA interviewed 5 staff. 2 out of 5 staff stated on 6/23/2022 around 8:30PM, R1 and R2 had alteration in their bedroom, they separated R1 and R2 immediately when they heard the noise. 3 out 5 staff stated they knew the incident occurred on 6/23/2022 between R1 and R2.

LPA interviewed 6 residents. 6 out of 6 residents were unable to describe what happened on 6/23/2022 evening.

Based on the interviews, R2 did not get physical abuse by staff. R1 and R2 had alteration in the bedroom in the evening, and staff separated them immediately when they heard the noise. Staff calm them down and they slept through the night. There is no evidence to indicate that the staff neglected residents or did not provide care and supervision to residents.

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.

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: 2 of 2