435202578-6-20-2025-26-AS-KHOS-DJDKGW-20250708075412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202578
Report Date: 06/20/2025
Date Signed: 06/20/2025 04:25:57 PM

Unsubstantiated

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
04/22/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20250422155235

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: 2	DATE:	06/20/2025
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Lead Staff Ronaldo Rapisura		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility is not kept clean and sanitary.
Facility staff are locking residents in their bedroom.
Facility did not ensure resident's medications were properly secured.
Facility did not properly maintain resident's cash resources.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver complaint investigation findings. LPA met with Lead Staff Ronaldo Rapisura, and explained the purpose of the visit.

On April 22, 2025, the Department received a complaint alleging, Facility is not kept clean and sanitary

On April 22 & 24, 2025, the Department interviewed Witness W1. W1 stated he/she visited the facility in April 2025 and observed the kitchen was dirty, with crumbs on the counter. W1 stated the floor did not look clean. W1 stated the fruit basket contained trash and the cabinet & dishes didn’t look clean.

On May 1, 2025, LPA Steve Chang interviewed facility Administrator and staff S1. S1 stated staff clean and mop the facility every day. ADM stated the staff clean the facility every day.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

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 6

Control Number 26-AS-20250422155235

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: CEDAR MANOR LLC	FACILITY NUMBER: 435202578
	VISIT DATE: 06/20/2025

NARRATIVE

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LPA Steve Chang toured the facility and made the following observations: LPA observed two bathrooms were clean and in sanitary condition. LPA checked the refrigerator and did not see expired food in the refrigerator.

On June 4, 2025, LPA Chang and Rai conducted a follow up complaint investigation visit. LPA’s Chang and Rai attempted to interview residents R1-R2. Both residents did not respond to questions posed by LPA’s. Both residents ignored LPA’s questions.
LPA’s Chang and Rai interviewed staff S2 and S3. Both staff interviewed stated they clean the facility everyday.

LPA Chang and Rai made the following observations during the complaint investigation visit: kitchen, common area, 2 bathrooms and 3 bedrooms to be in good repair and sanitary conditions.

On June 20, 2025, LPA Manuel Monter toured the facility inside and out, including but not limited to: kitchen, dinning area, living room, resident bedrooms, bathrooms. LPA was observed to be clean and sanitary.

LPA Monter interviewed Staff S4. S4 he/she cleans the facility during his/her shift. S4 stated he/she hasn't seen the facility in a dirty, unclean state.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Facility staff are locking residents in their bedroom.

On April 22, 2025, the Department received a complaint alleging, Facility staff are locking residents in their bedroom.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20250422155235

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: CEDAR MANOR LLC	FACILITY NUMBER: 435202578
	VISIT DATE: 06/20/2025

NARRATIVE

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On April 22 & 24, 2025, the Department interviewed Witness W1. W1 stated he/she visited the facility in April 2025. W1 stated he/she observed 2 resident bedrooms that were locked with residents inside. W1 stated he/she believes these residents are not able to make the decision to lock their bedroom door and able to unlock it.

On May 1, 2025, LPA Steve Chang interviewed facility ADM and staff S1. ADM stated by HCBS rule, the residents have the right to lock their rooms. ADM stated residents have the key to lock/unlock the doors. S1 stated the residents lock their rooms when they sleep. S1 stated the residents lock their rooms by themselves.

During the visit, LPA met resident R1. Resident R1 was able to show LPA how he/she can lock/unlock the his/her bedroom door.

On June 4, 2025, LPA Chang and Rai conducted a follow up complaint investigation visit. LPA’s interviewed staff S2 and S3. Staff S2 and S3 stated they have not seen or heard about staff locking residents in their bedrooms.

LPA Chang and Rai attempted to interview residents R1-R2. Both residents did not respond to questions posed by LPA’s. Both residents ignored LPA’s questions.

LPA Chang and Rai made the following observations during the complaint investigation visit: LPA Steve observed 3 bedrooms to be unlocked and 2 out of the 2 residents were not present at the facility as they were attending day program.

On June 20, 2025, LPA Manuel Monter toured the facility inside and out. LPA did not observe any resident locked inside their bedrooms. Based on observation, the residents bedroom doors only have a door knob. The door knob can be lock from the inside and out. During the visit, LPA observed both R1 and R2 unlock the bedroom door.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 26-AS-20250422155235

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: CEDAR MANOR LLC	FACILITY NUMBER: 435202578
	VISIT DATE: 06/20/2025

NARRATIVE

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LPA interviewed staff S4. S4 stated the residents can choose to lock their own bedroom door. S4 stated staff don't lock residents inside their bedroom.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Facility did not ensure resident's medications were properly secured.

On April 22, 2025, the Department received a complaint alleging, Facility did not ensure resident's medications were properly secured. It has been alleged that residents’ medications were not locked properly.

On April 22 & 24, 2025, the Department interviewed Witness W1. W1 stated he/she visited the facility in April 2025. W1 stated he/she observed medications that were out of the filing cabinet and were not locked properly.

On May 1, 2025, LPA Steve Chang toured the facility and made the following observations. LPA Chang observed the office, were residents’ medications are stored, was locked. LPA checked inside the office; LPA observed the facility has lock for resident medications.

On June 4, 2025, LPA Chang and Rai conducted a follow up complaint investigation visit. LPA’s Chang and Rai attempted to interview residents R1-R2. Both residents did not respond to questions posed by LPA’s. Both residents ignored LPA’s questions.

LPA Chang and Rai interviewed staff S2 and S3. Both staff interviewed stated medications are locked and properly secured.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20250422155235

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: CEDAR MANOR LLC	FACILITY NUMBER: 435202578
	VISIT DATE: 06/20/2025

NARRATIVE

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LPA Chang and Rai made the following observations: LPA’s observed the resident's medications were located in the facility office. The office door was locked and Administrator Elvira Casim located the key to unlock the office door. Once door was unlocked, Administrator pointed to the medication cabinet which was locked. Administrator located the key to unlock the cabinet and unlocked the cabinet. LPA Rai observed both resident's medications in the medication cabinet.

On June 20, 2025, LPA Manuel Monter toured the facility inside and out. LPA observed the medication storage area as locked an inaccessible to residents in care.

LPA interviewed Staff S4. S4 stated he/she hasn't seen the medications accessible to residents in care. S4 stated the medications for residents are locked.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Facility did not properly maintain resident's cash resources.

On April 22, 2025, the Department received a complaint alleging, Facility did not properly maintain resident's cash resources

On April 22 & 24, 2025, the Department interviewed Witness W1. W1 stated he/she visited the facility in April 2025. W1 stated he/she observed a discrepancy in R3’s P&I log. W1 stated R3 had less than $20 dollars, but his/her log stated he/she had more than $300.

On May 1, 2025, LPA Steve Chang conducted the initial complaint investigation visit. LPA Chang audited resident R2 and R3’s P&I. No discrepancies were noted.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 26-AS-20250422155235

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: CEDAR MANOR LLC	FACILITY NUMBER: 435202578
	VISIT DATE: 06/20/2025

NARRATIVE

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On June 4, 2025, LPA Chang and Rai conducted a follow up complaint investigation visit. LPAs interviewed Staff S2-S3. Both Staff interviewed stated he/she they handle the residents P&I.
LPA’s Chang and Rai attempted to interview residents R1-R2. Both residents did not respond to questions posed by LPA’s. Both residents ignored LPA’s questions.

LPA Rai reviewed resident's P&I records for June 2025 and observed the amount written on LIC 405 Record of Client's/Resident's Safeguarded Cash for Resources resident R1 & R2. LPA Rai counted 2 out of 2 resident P&I with Administrator and observed the same amount of money present in the resident's cash envelope.

On June 18, 2025, LPA Manuel Monter interviewed facility ADM and Licensee, Elvira & Anthony Casim. ADM/Licensee Stated the lead staff handles the P& I money. ADM/Licensee stated on the 15th of each month, they audit the residents P&I money. ADM/Licensee stated during their audits, there hasn’t been any issues noted.

On June 20, 2025, LPA Manuel Monter audited residents P&I records. LPA and staff S1 reviewed resident's P&I records for June 2025 and observed the amount written on LIC 405 Record of Client's/Resident's Safeguarded Cash for Resources resident R1 & R2. S1 counted 2 out of 2 resident P&I with LPA and observed the same amount of money present in the resident's cash envelope.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Page 6 Out of 6. END OF REPORT.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC9099 (FAS) - (06/04)

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