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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202671
Report Date: 11/16/2023
Date Signed: 11/16/2023 08:54:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/13/2022 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20220113083438
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:
11/16/2023
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Linda ArciagaTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Lack of supervision resulting in resident wandering away from facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannouced investigation visit and met with Licensee (LCN) Linda Arciaga to delivery the investigation finding.

On 01/13/2022, the Department received a complaint with the allegation that lack of supervision resulting in resident wandering away from facility.

On 01/18/2022, an unannouced initial investigation visit was conducted, Licensee, Aministrator and a staff (S1) were interviewed, resident's medical documents were obtained.


Continue on LIC9099-C. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023
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-20220113083438
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: EDRICBOYLYNN RESIDENTIAL CARE HOME INC
FACILITY NUMBER: 435202671
VISIT DATE: 11/16/2023
NARRATIVE
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Lack of supervision resulting in resident wandering away from facility:

On 01/12/2022, the Department received an incident report that resident R1 was missing. On 01/12/2022, around 10:00AM, resident R1 was found not in his/her room. Facility staff looked for R1 in the facility, backyard and neighborhood, but were unable to find R1. Facility staff notified Licensee immediately. Around 1:35PM, staff notified R1's family member, and at 1:50PM staff called police department. At 7:05PM, R1 was brought back to the facility by Police officers. Staff evaluated/assessed R1, no bruise or injury were found.

On 01/19/2022, LPA interviewed licensee Linda Arciaga (LCN). LCN stated he/she and staff (S1) drove the car to look for R1 till 6:00PM after he/she receive the notice from Administrator that R1 was missing, but were unable to find R1. LCN stated the facility was going to install audio alarm for the main entrance. LPA interviewed Administrator (ADM) Remedios Floresca. ADM stated R1 was last seen around 9:00AM on 1/12/2022, and he/she found R1 was missing around 10:00AM. ADM stated he/she notified LCN immediately. ADM stated R1's family member was notified around 1:35PM, and Police Department was notified at 1:50PM. R1 was brought back to the facility around 7:05PM on 1/12/2022. LPA interviewed staff S1. S1 confirmed he/she drove the car with LCN from morning to 7:00PM on 1/12/2022 to look for R1, but were unable to find R1.

Reviewing R1's physician report, R1 is ambulatory, sometimes confused and is unable to leave the facility without assistance. Based on the interviews and document reviewed, the facility staff were not aware of R1 going out the facility without notice. R1 wandered away from the facility, and was found by police officers. R1 was brought back to the facility by police officers.

The Department has investigated the above allegation. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D.Exit interview conducted with LCN. The report was provided to ADM for signature. A copy of this report was provided to LCN. Appeal Rights was provided.

Page 2 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20220113083438
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EDRICBOYLYNN RESIDENTIAL CARE HOME INC
FACILITY NUMBER: 435202671
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2023
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidence by:
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Licensee (LCN) stated to submit a plan of correction by POC due date to conduct staff training to ensure care and supervision are provided to residents to prevent elopement. LCN to submit the signatures of log of the training to CCL office.
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Based on interviews and records reviewed, on 1/12/2022, R1 eloped from the facility due to lack of supervision and was brought back by police officers. This posed an immediate health and safety rsik to resident 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: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3