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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202680
Report Date: 12/16/2022
Date Signed: 12/16/2022 03:37:49 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
02/28/2022 and conducted by Evaluator Christine Dolores
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220228083011
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:4CENSUS: 4DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Melda AntionioTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility has pests
Staff used resident’s items without permission
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings for the above allegations. LPA met with Administrator, Melda Antonio.

On 03/04/2022, the initial complaint investigation was conducted. The following documents were obtained to include R1 – R6’s physician’s report, needs and services plan, resident/client’s personal property and valuables form, facility’s staff schedule from 08/30/2021 – 10/03/2021, hours worked from 09/06/2021 – 09/19/2021, pest control invoices, pest control visit summary, and San Andreas Regional Center unannounced visit notes.

Page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
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 6
Control Number 26-AS-20220228083011
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: VINCI PARK ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202680
VISIT DATE: 12/16/2022
NARRATIVE
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Facility has pests
In October 2021, it was observed resident (R1)’s sweater contained small holes. During the clean-up of R1’s closet, it was observed R1’s closet contained rat/mice droppings. It was also observed that several of R1’s clothing was damaged by containing holes and being “gnawed” at several places possibly by the rat/mice.

Based on interview, the facility staff confirmed the observation of the rat/mice droppings inside R1’s room and the damage of the clothing items.

Facility staff took immediate action to deep clean the entire facility, throw out unnecessary junk, patched all the holes in the facility, and placed pest baits underneath crawl spaces around the facility.

In November 2021, the Administrator hired a professional pest control company as they continued to have pest activity despite the previous efforts.

Based on record review, the facility started a year-long contract with a pest control company in November 2021. The facility obtains a summary of each visit to include the date, personnel, type of service provided, and details.

Staff used resident’s items without permission
In August 2021, R1’s white t-shirt was observed on the kitchen floor of the facility being used as a mop by facility staff.

Based on interview, the facility staff assumed R1’s responsible party did want to keep R1’s white t-shirt since the facility staff mistakenly labeled the t-shirt in the wrong area. Facility staff instead used the t-shirt as a cleaning supply without the permission of R1’s responsible party.

Based on record review, in March 2021, the white t-shirt that was used without permission from R1’s responsible party was safeguarded under the resident/client’s personal property and valuables form. Page 2 of 3.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20220228083011
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: VINCI PARK ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202680
VISIT DATE: 12/16/2022
NARRATIVE
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The Department has conducted an investigation of the above allegations. Based on observation, interviews, and record review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC9099-D.

A civil penalty of $250 will be assessed for a repeat violation within 12 months of the initial citation. If the deficiency is not corrected within 24 hours, an additional $100 will be assessed until the deficiency is corrected. See LIC421FC.

A plan of correction was developed with Administrator, Melda Antonio. Exit interview conducted, a copy of this report along with the appeals rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20220228083011
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: VINCI PARK ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202680
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2022
Section Cited
CCR
80087(a)
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(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. This requirement is not met as evidenced by:
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The Licensee has corrected the deficiency prior to visit. Licensee will continue to take necessary measures to keep the facility free from pests.
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Based on observation, interview, and record review resident (R1)’s closet contained rat/mice droppings and clothing were damaged from the pests which poses a potential health, safety, and personal rights risk to persons in care.
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Type B
12/17/2022
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, including but not limited to notification of any modifications to the needs and services plan.This requirement is not met as evidenced by:
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Licensee will ensure to re-train staff on the resident's personal rights. Licensee will ensure to not use a resident's personal belonging unless given permission by a resident's authorized representative.
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Based on observation and interview, resident (R1)’s t-shirt was being used as a cleaning supply without the permission of R1 and R1’s responsible party which poses a potential health, safety, and personal rights risk to persons in care.
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Licensee will send the training documentation and statement of understanding to LPA via email by POC due date.
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: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
02/28/2022 and conducted by Evaluator Christine Dolores
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220228083011

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:4CENSUS: 4DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Melda AntionioTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has bed bugs
Facility staff are not reporting incidents
Residents left unsupervised while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings for the above allegations. LPA met with Administrator, Melda Antonio.

On 03/04/2022, the initial complaint investigation was conducted. The following documents were obtained to include R1 – R6’s physician’s report, needs and services plan, resident/client’s personal property and valuables form, facility’s staff schedule from 08/30/2021 – 10/03/2021, hours worked from 09/06/2021 – 09/19/2021, pest control invoices, pest control visit summary, and San Andreas Regional Center unannounced visit notes.

Facility has bed bugs
In November 2021, the facility had an unannounced visit with a facility liaison who observed the clients mattresses and body for beg bugs. No bed bugs were observed on the mattresses and no bed bug bites were observed on the residents at the facility. See LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20220228083011
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: VINCI PARK ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202680
VISIT DATE: 12/16/2022
NARRATIVE
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On 03/04/2022, three staff and one resident were interviewed. Three staff denied the observation of bed bugs at the facility. One resident denied the observation of bed bugs at the facility. During visit on 03/04/2022, LPA did not observe bed bugs at the facility.

Facility staff are not reporting incidents
In July 2021, it was alleged R1 had an incident of hitting his/her head against the bed headboard. The incident was reported from R1’s roommate.

On 03/04/2022, three staff were interviewed. Three out of three staff denied any serious incidents that had in the facility from July 2021 - March 2022.

Resident left unsupervised while in care
On 09/16/2021, resident (R1) was dropped off at the facility from an outing, when it was alleged the residents inside the home were left unsupervised while the staff was mowing the lawn.

On 03/04/2022, three staff members were interviewed. Based on interview, the residents are never left unsupervised. On the day of the incident, staff (S2) and staff (S3) were scheduled to work that evening. S2 was inside the facility supervising the residents while S3 was mowing the lawn.

On 03/04/2022, one resident (R2) was interviewed. Based on interview, the residents have never been left unsupervised at the facility.

Based on record review, on 09/16/2021, there were two staff (S2 – S3) who were scheduled that evening.

The Department has investigated the above allegations. Based on interviews, observation, and records reviewed the allegations listed above are UNSUBSTANTIATED. An unsubstantiated finding means that although the alleged violations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No Deficiencies cited under California Code of Regulations Title 22. This report was reviewed with Administrator, Melda Antonio and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6