435202592-1-23-2024-26-AS-RMAO-D25249-20240203160335

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202592
Report Date: 01/23/2024
Date Signed: 01/23/2024 03:57:21 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
10/21/2021 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20211021160711

FACILITY NAME:	FOOTHILL ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	435202592
ADMINISTRATOR:	ANGELICA ATRIANO		FACILITY TYPE:	735
ADDRESS:	13655 FOOTHILL AVE		TELEPHONE:	(669) 231-3861
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY:	4	CENSUS: 4	DATE:	01/23/2024
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Administrator, Bonnie Jirzcek and House Manager, Charmaine Ah Kuoi		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff handled resident in a rough manner.
Staff did not treat resident with dignity.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to obtain further information and conclude the complaint investigation. LPA Rai met with Administrator Bonnie Jirzcek and House Manager Charmaine Ah Kuoi and stated the purpose of the visit.

On 10/21/2021, the Department received a complaint with the above allegations. On 10/26/2021, the Department conducted an initial investigation.

During today's visit, LPA Rai conducted interviews with 3 staff (S1-S3). LPA Rai reviewed documentations of staff notes regarding the incident which occurred on 10/20/2021.

Continuation on LIC 9099-C, Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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 3

Control Number 26-AS-20211021160711

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: FOOTHILL ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 435202592
	VISIT DATE: 01/23/2024

NARRATIVE

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Page 2 of 3.

Staff handled resident in a rough manner.
On 10/20/2021 at 1:00pm an incident occurred at the facility wherein resident (R1) reported to facility staff about Staff S1 “took him/her to the floor”. Resident was not able to explain the details of the incident but R1 stated S1 put him/her on the floor.

On 10/26/2021, the Department conducted an interview with Administrator (ADM), who stated the facility did an internal investigation and there was no evidence of the event occurring.

Per record review of staff schedule from 10/18/2021-10/24/2021, S1 was not on the schedule to work on 10/20/2021.

On 12/6/2023, the Department conducted an interview with Current Administrator (CADM) who stated there wasn’t an incident recorded where S1 took resident to the floor.

On 1/23/2024, LPA Rai interviewed 3 staff at the facility. 3 Out of 3 staff stated they did not observe staff handing R1 in a rough manner. 3 Out of 3 staff stated R1 did have behavioral episodes where staff did need to use Ukeru pads and/or temporary holds during an episode. 3 Out of 3 staff stated they did not observe staff being rough or physical with R1 outside of temporary hold.

Based on record review of R1’s Individual Support Plan on 9/9/2021 through 11/10/2021, R1 had incidents of physical intimidation with residents and staff, verbal aggression, and aggressive behavior. Based on R1’s Needs and Service Plan 6/15/2021, R1 has become aggressive towards family members, peers and staff in multiple residential locations and the facility’s plan is to be monitored while in common areas with one-to-one supervision.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20211021160711

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: FOOTHILL ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 435202592
	VISIT DATE: 01/23/2024

NARRATIVE

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Page 3 of 3.

Staff did not treat resident with dignity.
On 10/20/2021 at 1:00pm an incident occurred at the facility wherein resident reported to the facility staff that Staff 2 (S2) threw water directly at his/her face.

On 10/26/2021, the Department conducted an interview with Administrator (ADM), who stated S2 and R1 were playing R1's favorite game with water. ADM stated they did an internal investigation and there was no evidence of R1 not being treated with dignity during the incident.

On 12/6/2023, the Department conducted an interview with Current Administrator (CADM) who stated R1 liked the waterlog ride at Santa Cruz Beach Boardwalk and often times the facility staff would imitate the ride in the backyard by pushing R1 with a chair on wheels and staff would squirt water bottle to wet him/her. CADM stated the facility did an internal investigation and there was no foul play.

On 1/23/2024, LPA Rai interviewed 3 staff members during visit. 3 Out of the 3 staff stated they did not observe S2 not treating resident with dignity. S3 stated he/she was present during the incident and stated S2 did not throw water directly at his/her face, but they both were trying to recreate the log ride and the water bottle was creating a mist over R1 and the water bottle was not aimed towards his/her face.

During the time of this investigation, the Department made multiple attempts to reach out to S2 on the phone but was not successful. S2 is no longer employed by the facility. During the time of this investigation, R1 moved out of the facility and the Department made multiple attempts to reach out to R1 on the phone but was not successful.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from the California Code of Regulations, Title 22. Exit interview conducted with Administrator Bonnie Jirzcek and House Manager Charmaine Ah Kuoi. A copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

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