435202629-6-6-2023-26-AS-RMAO-CTU25L-20230717170540

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202629
Report Date: 06/06/2023
Date Signed: 06/06/2023 11:15:24 AM

Unfounded

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
05/11/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230511135626

FACILITY NAME:	BLENDED FAMILY CARE HOME		FACILITY NUMBER:	435202629
ADMINISTRATOR:	PAGKALINAWAN, MICHELLE		FACILITY TYPE:	740
ADDRESS:	10366 MILLER AVENUE		TELEPHONE:	(408) 802-6410
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY:	12	CENSUS: 8	DATE:	06/06/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Administrator Michelle Pagkalinawan		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Licensee is in financial distress.
Licensee takes 1st month advancement rental deposit for care.

INVESTIGATION FINDINGS:

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On 6/6/2023 LPA conducted an unannounced complaint investigation/inspection to deliver investigative findings on the above two allegations and met with Administrator Michelle Pagkalinawan.

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

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

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-20230511135626

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: BLENDED FAMILY CARE HOME	FACILITY NUMBER: 435202629
	VISIT DATE: 06/06/2023

NARRATIVE

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Page 2 of 3.
Licensee is in financial distress

On 5/11/2023, interviews were conducted with Administrator (ADM), ADM denied that corporation is in financial distress. ADM stated 'care and supervision' of residents is their utmost duties and responsibilities.

ADM stated that they have a payroll company who does their employees' payroll and all staff are paid twice (2x) a month with no delay. During inspection, the facility food supplies and non-food supplies were inspected and met the required Title 22 regulations on 5/11/2023, which requires 2 days perishable and 7 days non-perishables. Non-food supplies such as toiletries and cleaning supplies were also inspected. ADM stated that they are not behind with utility bill payments such as PG&E, cable and internet. ADM provided copies of utility bills paid in the last 3 months including receipts of food supplies and staff payroll documents.

During interview with ADM, ADM did not deny about non-payment of their monthly rental for the past 4-5 months, however, due to a lease agreement dispute between the corporation and the landlord the licensee is not paying the landlord. ADM stated that the facility was not able to generate income for two private vacant bedrooms for a couple of months due to mold growth in the area. ADM stated that the landlord is unwilling to cooperate in the terms and conditions of their lease agreement that the corporation has the right to hold rental payments. According to the Lease agreement between landlord and Licensee under Damage and Destruction, “Tenant shall be relieved from paying rent and other charges during any portion of the Lease term that the Leased Premises are inoperable or unfit for occupancy, or use, in whole or in part, for Tenant’s purposed” (California Commercial Lease Agreement effective 2017, Page 3-4).

Licensee takes 1st month advancement rental deposit for care.

Based on interview with Administrator (ADM), ADM stated that the facility does not take 1st month advance rental deposit for care. The Department obtained copies of 8 Out of 8 residents' admission agreements in which none of the 8 residents paid a 1st month rental deposit for care, or preadmission fee.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20230511135626

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: BLENDED FAMILY CARE HOME	FACILITY NUMBER: 435202629
	VISIT DATE: 06/06/2023

NARRATIVE

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Page 3 of 3.

ADM stated that they require prospective residents and/or their responsible party to hold a room for 7 days payable half of the rent agreed upon whether a private or shared bedroom which is fully refundable. ADM stated that if prospective resident and/or family member decides not to avail the bedroom, they provide a full refund. For residents and/or responsible family members who decides to be admitted to the facility, they would only require resident and/or responsible family member to pay 1/2 of the rent which goes to the first month's rent along with the 7 day hold fee.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited during today's visit. Report was discussed with and a copy provided to Michelle Pagkalinawan.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3