435202684-8-24-2023-26-AS-RMAO-CVUSJ3-20230920135427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202684
Report Date: 08/24/2023
Date Signed: 08/24/2023 04:20:14 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, 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
08/16/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20230816132913

FACILITY NAME:	MOMENTUM FOR MENTAL CRISIS RESIDENTIAL		FACILITY NUMBER:	435202684
ADMINISTRATOR:	CHRISTINE ROSSI		FACILITY TYPE:	772
ADDRESS:	101 JOSE FIGURES		TELEPHONE:	(408) 254-6828
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	16	CENSUS: 13	DATE:	08/24/2023
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Christina Rossi		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility has bed bugs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced initial complaint investigation visit and met with Administrator (ADM) Christina Rossi.

LPA interviewed ADM, Director of Licensing and Regulations (S1), Program Manger (S2), two other staff (S3, S4), and 4 residents.

LPA toured and inspected 5 bedrooms with S2, and checked bedbugs for 4 beds/mattresses.

Current client roster, and client roster from 6/25/2023 to 7/31/2023 were obtained. Resident Physician report, discharge document, Appraisal Needs and Service Plan and Progress Notes were also obtained.

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: 08/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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 2

Control Number 26-AS-20230816132913

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: MOMENTUM FOR MENTAL CRISIS RESIDENTIAL	FACILITY NUMBER: 435202684
	VISIT DATE: 08/24/2023

NARRATIVE

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Facility has bed bugs:
Resident R1 moved in the facility on 6/27/2023, and discharged on 7/27/2023. R1's roommate R2 moved in facility on 6/24/2023, and discharged on 8/4/2023. R1 and R2 were unable to contact.

LPA toured and inspected 5 resident bedrooms including the bedroom which R1 and R2 lived before, no flies, cockroach or insects were observed. LPA checked 4 beds/mattresses including the two bed for R1 and R2 before for bedbugs with S2, no bedbugs were observed.

LPA interviewed ADM, S1 and S2. 3 out of 3 stated on 7/25/2023, the facility received a phone call complained about the bedbug in the bedroom. The facility sent maintenance staff to check immediately, and did not find any bed bugs. 3 out of 3 stated other than the complaint of the phone call on 7/25/2023, there are no any complaint regarding bedbugs in the facility for year 2023.

LPA interviewed maintenance staff (S4) and house cleaning staff (S5). Both of them stated they did not find bedbugs in the facility. LPA interviewed 4 residents (R3 - R6). 4 out of 4 stated they did not find any bedbugs in the facility.

LPA reviewed R1's physician report, Appraisal Needs and Service plan, and Progress Note, R1 did not have delusion, or fabrication of story. R1 had emotional dysregulation and depression.

Based on the inspection and observation conducted, and interviews conducted, there were no evidence to show that there were bedbugs in the facility.

The department has investigated the above allegation. Based on the investigation, observations, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No citation noted today. The report was provided to ADM for signature. A copy of the report was provided to ADM.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2