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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202680
Report Date: 04/07/2022
Date Signed: 04/07/2022 04:27:45 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
04/01/2022 and conducted by Evaluator Christine Dolores
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220401112933
FACILITY NAME:VINCI PARK ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202680
ADMINISTRATOR:MELDA RIPARIP ANTONIOFACILITY TYPE:
735
ADDRESS:5875 HERMA STREETTELEPHONE:
(408) 518-2250
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 5DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:MELDA RIPARIP ANTONIOTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff is using a client's personal laptop without proper authorization
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open an initial complaint investigation and met with Administrator Melda Antonio.

During visit, LPA interviewed two staff members and obtained the following documents to include: R1's Individual Program Plan (IPP) and Appraisal Needs and Services Plan.

Two out of two staff members stated an incident where staff had used a client's personal laptop without authorization. S2 stated to assist R2 with a virtual day program when R2's laptop was on low battery. S2 used R1's laptop for R2's virtual day program without receiving proper authorization and consent from R1 and R1's conservator / authorized representative.

See LIC 9099-C for additional information.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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-20220401112933
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: VINCI PARK ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202680
VISIT DATE: 04/07/2022
NARRATIVE
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The Department has conducted an investigation of the above allegation. Based on interviews and record review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. A deficiency is being cited. See LIC 9099-D.

Exit interview conducted with Administrator Melda Antionio. A copy of this report, along with the facility's appeals rights were provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20220401112933
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: VINCI PARK ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202680
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2022
Section Cited
CCR
85072(b)(2)
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(b) The licensee shall insure that each client is accorded the following personal rights.(2) To have the facility inform his/her relatives and authorized representative, if any, of activities related to his/her care and supervision... This requirement is not met as evidence by:
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Licensee will review sections 85072 and 80072 and provide an in-service training to staff on sections above. Licensee will submit a statement of understanding to LPA via email by POC date of 04/14/2022.
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Based on interviews and record review, the licensee did not ensure to inform R1's authorized representative of the use of R1's personal laptop for R2's virtual day program which poses a potential Health, Safety, and 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: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3