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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202671
Report Date: 04/06/2021
Date Signed: 04/06/2021 05:13:24 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2020 and conducted by Evaluator Mohamed Filouane
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20200309105610
FACILITY NAME:EDRICBOYLYNN RESIDENTIAL CARE HOME INCFACILITY NUMBER:
435202671
ADMINISTRATOR:ARCIAGA, LINDAFACILITY TYPE:
735
ADDRESS:1307 PARK PLEASANT CIRTELEPHONE:
(408) 929-4958
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 5DATE:
04/06/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Linda ArciagaTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Staff put clear masking tape around client's helmet and gloves.
INVESTIGATION FINDINGS:
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On 04/06/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up complaint inspection with Administrator Linda Arciaga over the phone. Due to COVID-19 and health and safety concerns, LPA was not present in the facility. LPA spoke with the home operator, explained the purpose of the phone call, and then delivered the findings.

Concerning the allegation of staff putting clear masking tape around the client's helmet and gloves, LPA Filouane investigated, interviewed the Administrator, and requested the doctor's order for the resident's helmet and gloves. The Administrator did not deny the allegation and confirmed that staff has been using clear masking tape on the client's helmet and gloves to keep the adhesive strip attached. The Administrator stated the adhesive strip would detach as the client wore the helmet throughout the day. The clear masking tape was not touching skin and was placed to help keep the adhesive strip attached.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
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 2
Control Number 26-AS-20200309105610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: EDRICBOYLYNN RESIDENTIAL CARE HOME INC
FACILITY NUMBER: 435202671
VISIT DATE: 04/06/2021
NARRATIVE
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The helmet and gloves aid to prevent injuries, as ordered by the physician. LPA Filouane gathered the physician's order that stated the resident must wear a helmet and gloves to protect from self-inflicted injury.

LPA Filouane conducted a video call with the Administrator and asked the client if they could remove the helmet on their own. During the video call, the client removed their helmet without assistance.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with the Administrator over the phone. The Administrator will receive this LIC9099 report through email or mail to sign and then will email or mail the signed version back to the LPA.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2