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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202651
Report Date: 02/10/2024
Date Signed: 02/10/2024 02:30:07 PM

Substantiated


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
11/21/2023 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20231121085509
FACILITY NAME:MERIDIAN MANOR IVFACILITY NUMBER:
435202651
ADMINISTRATOR:EMMANUEL G FERNANDOFACILITY TYPE:
735
ADDRESS:1502 CONSTANSO WAYTELEPHONE:
(408) 882-3908
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:3CENSUS: 3DATE:
02/10/2024
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Staff June MaligTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Facility staff had an altercation at the facility violating residents' personal rights.
Facility did not submit incident report regarding altercations between two staff to CCL office.
INVESTIGATION FINDINGS:
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On November 21, 2023, the Department received a complaint that personal rights of residents were violated due to staff altercation, and the facility did not submit an incident report regarding staff altercation to licensing office.

On November 28, 2023, the department conducted an initial investigation and inspection by Licensing Program Analyst (LPA) Steve Chang. During the visit, LPA met and interviewed Administrator (ADM). ADM stated that he/she was on vacation when the incident occurred, but he/she received a call from another staff about it. ADM stated that two male staff (referred as S1 and S2) had a misunderstanding which led to a physical altercation in the facility, but no reported injuries by both staff on September 16, 2023.

On November 28, 2023 and February 10, 2024, the department attempted to interview residents R1-R3. 3 Out of 3 residents are non-verbal and were unable to answer LPA's questions.
Page 1 out of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
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 4
Control Number 26-AS-20231121085509
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: MERIDIAN MANOR IV
FACILITY NUMBER: 435202651
VISIT DATE: 02/10/2024
NARRATIVE
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LPA met and interviewed Staff (S1) regarding the incident between him/her and S2. S1 confirmed that the altercation occur on September 16, 2023 at around 4PM-5PM. S1 stated that S2 met someone (in social Media) wherein S2 has been spending a log of time chatting/talking instead of focusing on his/her work. S1 confronted S2 about his/her spending time chatting/talking resulted in verbal and physical altercation.

LPA did not interview S2. S2 is no longer employed at this facility as of November 15, 2023.

Based on available information gathered, S1 heard S2 on the phone with someone. S1 heard his/her name being mentioned by S1 about inappropriate comment about S1. S1 confronted S2 resulted in verbal and physical altercation inside the facility family room area.

Based on investigation, the ADM and/or staff designee did not submit an incident report regarding S1 and S2's physical and verbal altercation in September 2023. LPA Chang is the assigned caseload LPA for this facility and confirmed not receiving LIC624. (Unusual incident Report.)

On February 10, 2024, LPA interviewed ADM. ADM stated he did not send an incident report regarding S1 and S2's altercation on September 16, 2023. ADM stated he did not send the incident report because the altercation did not involve residents. ADM stated the staff cannot fight, and "that's prohibited and against company policy." ADM stated if staff have a grievance, then staff can come to him to resolve it.

Based on interview and record review, the above two allegations that the facility staff had an altercation in the facility that violates residents' personal rights, and the facility did not submit a written report within 7 days. Therefore, the Department found the above allegations to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Administrator Emmanuel G Fernando. ADM stated Staff S1 could sign on her behalf and a signed copy of this report was provided along with appeal rights.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20231121085509
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: MERIDIAN MANOR IV
FACILITY NUMBER: 435202651
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2024
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement was not met as evidenced by;
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ADM stated he will send letter of understanding regarding the regulation. ADM stated he will send letter to LPA by POC date, 02/17/2024.
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Based on record review and interviews conducted, Staff S1 and S2 engaged in a verbal and physical altercation inside the facility on September 16, 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
02/17/2024
Section Cited
HSC
80061(b)(1)(E)
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80061 Reporting Requirements (b)(1)(E) Any unusual incident ... threatens the physical or emotional health or safety of any client... in and of itself, constitute an unusual incident unless it meets the criteria specified for mandated reporting... This requirement was not met as evidenced by;
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ADM stated he will send letter of understanding regarding the regulation. ADM stated he will send letter to LPA by POC date, 02/17/2024.
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Based on interviews & record reviewed, the facility did not send an incident report for the altercation between S1 & S2, which occurred on 9/16/2023. ADM confirmed he did not send an incident report. This poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20231121085509
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: MERIDIAN MANOR IV
FACILITY NUMBER: 435202651
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2024
Section Cited
CCR
80065(a)
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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement was not met as evidenced by;
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ADM stated he will send letter of understanding regarding the regulation. ADM stated he will also send plan of action stating how he plans to ensure staff are competent to provide the services necessary to meet individual client needs and shall, at all times.
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Based on record review and interviews conducted, two staff did not preform their duties and responsibilities to foster a safe environment in the facility, when they engaged in a physical altercation. This poses/posed a potential health, safety or personal rights risk to persons in care.
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ADM stated he will send plans of correction by POC date, 02/17/2024.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4