435202647-9-23-2025-26-AS-RMAO-DMEKHV-20251013075547

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202647
Report Date: 09/23/2025
Date Signed: 09/23/2025 01:35:39 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
08/14/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20250814155156

FACILITY NAME:	PARKSIDE VILLA INC		FACILITY NUMBER:	435202647
ADMINISTRATOR:	FORONDA-CAYABYAB, MARIE		FACILITY TYPE:	740
ADDRESS:	300 S 22ND ST		TELEPHONE:	(408) 831-7411
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95116
CAPACITY:	15	CENSUS: 15	DATE:	09/23/2025
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Lead Staff Felicitas Ventura		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Staff did not allow client to return to the facility upon discharge from Hospital

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Lead Staff Felicitas Ventura, who contacted facility Administrator via phone call. ADM stated she was currently at a meeting. ADM stated her lead staff, Felicitas Ventura could sign on her behalf.

On August 14, 2025 the Department received a complaint alleging Staff did not allow client to return to the facility upon discharge from Hospital.

Page 1 Out of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

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 3

Control Number 26-AS-20250814155156

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: PARKSIDE VILLA INC	FACILITY NUMBER: 435202647
	VISIT DATE: 09/23/2025

NARRATIVE

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On August 5, 2025, the Department received an incident report for resident R1. The incident report stated, On August 4, 2025, at approximately 5:00 PM, R1 approached kitchen staff while they were doing dishes and R1 stated that he/she was "having an episode," (this usually means that R1 is about to have an outburst or a meltdown). Staff noticed that R1's voice began to escalate in volume. Another staff member overheard the interaction and attempted to redirect R1 by inviting him/her outside for fresh air and a conversation. Staff then asked R1 if he/she would like to take his/her PRN medication, and R1 agreed. However, while staff were preparing the PRN medication, R1 suddenly became physically aggressive, thinking that staff were talking about him/her. R1 misinterpreted a conversation between two staff members about food as being directed at R1. R1 then attacked a staff member attempting to choke him/her. Other staff immediately intervened and R1 eventually released the staff member. Staff called 911 for police assistance. Police and paramedics arrived shortly thereafter. Paramedics assessed and assisted the injured staff. R1 was subsequently transported to the hospital for further evaluation and intervention.

On August 22, 2025, LPA Monter interviewed staff S1 and ADM. S1 stated on August 4, 2025, R1 stuck a staff member around 5pm. S1 stated R1 was taken to the hospital that day by the police. S1 stated on August 5, 2025, hospital staff spoke with ADM. S1 stated the ADM requested if R1 can stay for another night. S1 stated the ADM spoke to a staff at the hospital who confirmed with the doctor at the hospital that R1 can stay for 1 more night, but R1 needed to be picked up the following day. S1 stated R1 was picked up on August 6, 2025, around 11:30am.

ADM stated the timeline of events were as follows: On August 4, 2025, R1 had a violent behavior towards staff and the police were contacted, and R1 was taken to the hospital. ADM stated she was contacted the next day around 1:00pm. ADM stated she asked hospital staff if R1 could stay an additional night. ADM stated hospital staff confirmed it was ok for R1 to stay an additional night. ADM stated R1 was picked up on August 6, 2025.

LPA Monter interviewed staff S1. S1 stated he/she was at the facility on August 4- 6, 2025. S1 stated on August 4, 2025, R1 stuck a staff member around 5pm. S1 stated R1 was taken to the hospital by the police. S1 stated the next morning (August 5, 2025), hospital staff spoke with ADM. S1 stated the ADM requested if R1 can stay for another night. S1 stated the ADM spoke to a staff at hospital who said he/she would relay info to the doctor. S1 stated Around 4pm, ADM called again, and hospital staff confirmed that R1 can stay for 1 more night but picked up the following day. S1 stated R1 was picked up on August 6, 2025, around 11:30am. Page 2 Out of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 26-AS-20250814155156

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: PARKSIDE VILLA INC	FACILITY NUMBER: 435202647
	VISIT DATE: 09/23/2025

NARRATIVE

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On August 25, 2025, LPA Monter interviewed Witness W1. W1 stated on August 5, 2025, he/she was called by hospital staff, who stated the care home asked to keep R1 for another night. W1 stated he/she tried to get a hold of the care home. W1 stated he/she didn’t get response that day. W1 stated the next day, he/she was informed by the care home that they would pick R1 up that day. (August 6, 2025)

On August 26, 2025, LPA Monter contacted the hospital where R1 stayed. Hospital staff informed LPA they could not provide any information regarding R1’s stay at the hospital, as he/she is no longer currently staying at the hospital and also due to HIPPA.

On August 26, 2025, LPA Monter interviewed R1's Service coordinator (SC). SC stated, once the hospital determines it’s a safe discharge, then the care home is supposed to accept R1 back. SC stated if there is a concern, violent, danger or violent. Then the facility can discuss with hospital and talk to the psychiatrist and doctor and come up with a plan. SC stated R1 returned to the facility on August 6, 2025.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation was 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 allegation did or did not occur.

No deficiencies were cited from California Code of Regulations, Title 22 during today’s visit. This report was reviewed with Administrator MARIE FORONDA-CAYABYAB and a copy of the report was provided.
Page 3 Out of 3. END OF REPORT.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

LIC9099 (FAS) - (06/04)

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