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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202671
Report Date: 02/08/2024
Date Signed: 02/09/2024 01:11:39 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
03/21/2022 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20220321162213
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:
02/08/2024
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Remedios FlorescaTIME COMPLETED:
12:39 PM
ALLEGATION(S):
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Facility has roaches.
Staff are not trained to meet the residents needs.
Facility violates residents personal rights.
Facility has inadequate lighting in the hallway.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with House manager (HM) Remedios Floresca.

On 3/21/2022, the Department received a complaint with the above allegations.

On 3/29/2022, an initial investigation visit was conducted, Administrator (ADM) and 1 staff (S1) were interviewed. An inspection tour of the facility was conducted.

On 11/16/2023, LPA conducted an investigation visit, and interviewed staff and residents.


Continue on LIC9099-C. Page 1 of 4.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
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 10
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
03/21/2022 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20220321162213

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:
02/08/2024
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Remedios FlorescaTIME COMPLETED:
12:39 PM
ALLEGATION(S):
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Facility stores expired food.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with House Manager (HM) Remedios Floresca.

On 3/21/2022, the Department received a complaint with the above allegations.

On 3/29/2022, an initial investigation visit was conducted, Administrator (ADM) and 1 staff (S1) were interviewed. An inspection tour of the facility was conducted.

On 11/16/2023, LPA conducted an investigation visit, and interviewed staff and residents.

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

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 26-AS-20220321162213
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: 02/08/2024
NARRATIVE
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Facility stores expired food:

On 3/29/2022, LPA interviewed ADM and checked the perishable food supplies, nonperishable food supplies and milks. LPA did not find expired food supplies or expired milk. LPA observed the perishable food was not ample. ADM stated today is the scheduled grocery shopping day. During the interview, LPA observed the facility staff finished grocery shopping and brought perishable food and nonperishable food in facility. ADM and house manager (HM) denied the facility provided expired food to residents.

On 11/16/2023, LPA interviewed 3 residents (R1 - R3). 3 out of 3 residents stated they were not aware of the facility having expired food.

The Department has investigated the above allegation. Based on interviews and observation, the department has found the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid, there is not a preponderance of evidence to show the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22.

Exit interview was conducted with HM. This report was provided to HM for signature. A copy of the report was provided to HM.


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

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 26-AS-20220321162213
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: 02/08/2024
NARRATIVE
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Facility has roaches:

On 3/29/2022, LPA interviewed Administrator (ADM) Linda Arciaga and House Manager (HM), and toured the facility with HM. LPA toured the kitchen, family room, dining area, restrooms and bedrooms. LPA did not find roaches. Both ADM and HM stated the facility had roaches before, and the facility hired an exterminator company to eradicate roaches, and the company still came in monthly for checking and treatment.

On 11/16/2023, LPA interviewed ADM. ADM provided the exterminator reports. ADM stated the exterminator company still comes in facility to check every 3-4 months.

Based on the interviews, the facility had roaches before and the facility was under the exterminator company's treatment for roaches.

Staff are not trained to meet the residents needs:

On 3/29/2022, LPA interviewed Administrator (ADM) and House manager (HM). ADM was unable to provide the documents of the training of behavior or psychiatric for the staff. HM stated the facility staff started psychiatric training 1 month ago, but the facility still unable to provide the documents.

On 11/16/2023, LPA interviewed ADM, ADM provided the documents of staff behavior training.

Based on the reviews of the training documents, the training were provided by SARC and the training were provided to the staff after the facility was found the deficiency that the staff did not receive training to provide care and supervision to mental disorder residents.

Based on the interviews and observation, the facility retains residents with mental disorders, but the facility staff did not receive behavior training before the staff to provide the service and care to residents.


Continue on LIC9099-C. Page 2 of 4.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 26-AS-20220321162213
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: 02/08/2024
NARRATIVE
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Facility violates residents personal rights:
On 3/29/2022, LPA interviewed Administrator (ADM) and House Manager (HM). Both stated resident (R1) was overweight and liked to continue to eat. HM stated the facility provided regular 3 meals for R1, just asked R1 not to have extra food. HM stated there was no doctor's order to restrict R1's food. HM stated dietitian told the facility to help R1 to reduce the amount of food eating. HM stated the facility did not have dietitian order in writing. HM stated based on years of care and supervision experience, the staff asked R1 not to eat too much for snack. HM stated the facility staff asked R1 not to eat too much is for R1's health, not for saving the facility expense.

On 1/27/2023, LPA conducted another complaint, LPA observed R1 was overweight and interviewed R1. R1 did not complain the food was not adequate. On 11/16/2023, LPA interviewed R1. R1 was observed thinner than 1/27/2023. R1 stated the facility provided regular 3 meals. R1 stated the facility did not really restrict him/her to access food, but kept telling her not to eat too much snack for his/her health when he/she was going to eat snack. R1 stated he/she does not like snacks anymore and does not eat snack now.

Based on the observation and interviews, there was no doctor order for R1's to lose weight or to restrict R1's food, the facility staff limited R1's snack access.

Facility has inadequate lighting in the hallway:
On 3/29/2022, LPA interviewed Hose Manager (HM) and toured the facility with HM. HM stated several days ago, a visitor came to the facility and found the light of the hallway was not working. HM stated the facility had fixed it 2 - 3 hours after the visitor left the facility. HM stated the facility provided care and supervision to residents during the time period of the hallway light was not working, it did not have the immediate risk for the residents' safety during the time period. LPA checked the hallway, and found it was bright during the inspection.

On 11/16/2023, LPA interviewed ADM. ADM stated the hallway light was not broken. The hallway light bulb was too low, the facility already changed to a brighter light bulb.

Based on the interviews, the lighting in the hallway was inadequate.

Continue on LIC9099-C. Page 3 of 4.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 26-AS-20220321162213
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: 02/08/2024
NARRATIVE
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The Department has investigated the above allegations and the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D.

This report was reviewed with HM and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 26-AS-20220321162213
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: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2024
Section Cited
CCR
80087(a)(1)
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80087 Buildings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
(1) The licensee shall take measures to keep the facility free of flies and other insects.
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The facility already hired externator company to eradicate roaches. ADM stated to submit a plan of correction by the POC due date to LPA.
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This requirement was not met as evidenced by:
Based on interviews: the facility staff stated the facility had roaches and hired exterminator company to eradicate roaches. This posed a potential health and safety risk to residents in care.
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Type B
02/15/2024
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.
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The facility already had the staff to receive the training of behavior. ADM stated to submit a plan of correcction by the POC due date to CCL office.
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This requirement was not met as evidenced by:
Based on the interviews and observation, the facility staff did not receive training of behavior to provide care and supervision residents. This posed a potential health and safety risk to residents 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: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 26-AS-20220321162213
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: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2024
Section Cited
CCR
80076(4)
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80076 Food Services. (4) Between meal nourishment or snacks shall be available for all clients unless limited by dietary restrictions prescribed by a physician.
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Administrator stated to provide a plan of correction by the POC due date to provide training of personal right to staff.
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This requirement was not met as evidenced by:
Based on interviews, the facility limited resident to access snacks. This posed a potential personal rights risk to residents in care.
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Type B
02/08/2024
Section Cited
CCR
80088(d)
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80088 Furniture, Fixtures, Equipment, and Supplies. (d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.
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The facility already fix the issue and provides bright lighting in the hallway. Administrator stated to provide a plan of correction by the POC due date.
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This requirement was not met as evidenced by:
Based on interviews and observation, the facility did not provide bright lighting in the fancily hallway. This posed a potential safety risk to residents 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: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 10 of 10