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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202728
Report Date: 05/13/2025
Date Signed: 05/13/2025 11:17:27 AM

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
09/13/2022 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20220913094545
FACILITY NAME:SYCAMORE HOMEFACILITY NUMBER:
435202728
ADMINISTRATOR:NOEL HUANTEFACILITY TYPE:
737
ADDRESS:15160 SYCAMORE AVETELEPHONE:
(408) 915-5970
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY:4CENSUS: 4DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Director of Operations David SandhuTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff not providing adequate supervision to residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with ADM Administrator Noel Huante.

On September 13, 2022, the Department received a complaint alleging Staff not providing adequate supervision to residents in care. It has been alleged that on September 12, 2022, a resident eloped from the facility and entered a neighbors home.

On September 15, 2022, LPA Ryker Heberle conducted an initial investigation.

On December 13, 2023, LPA Maruffo interviewed Facility Administrator Huante. ADM stated that she does not have any incident report or internal report of Sequia eloping from the facility on 09/11/2022.
Page 1 Out of 3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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-20220913094545
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: SYCAMORE HOME
FACILITY NUMBER: 435202728
VISIT DATE: 05/13/2025
NARRATIVE
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On January 28, 2025, LPA Monter interviewed ADM. ADM stated there has been an elopement in the past, back in September 2022. ADM stated R1 entered back gate. ADM stated the staff was following the resident, but stated the ground is uneven, making it difficult to pursue, meanwhile resident R1 ran without precaution. ADM stated R1 kept running, and ran up the hill, to the exiting fence. ADM stated R1 jumped the fence. ADM stated the staff who followed R1 was afraid to jump the fence. ADM stated that staff member didn’t go down and watched R1 keep running. ADM stated another staff went around the neighborhood, in a vehicle. ADM confirmed that R1 did manage to get inside a neighbor’s home. ADM stated R1 was in the home for a few minutes.

Based on a review of facility incident report dated September 12, 2022, “R1 was playing in the backyard with a staff member. R1 pushed through the back gate and went to play on a concrete slab. While Staff member was standing beside R1, R1 suddenly ran towards the top of the mound at the edge of the property. R1 climbed over the fence and jumped down to the other side. Staff was in pursuit when he/she tripped over a goffer hole, causing him/her to fall. R1 then ran towards the neighbor’s house. Staff called for backup because it was not safe to jump the fence. Staff drove around to the neighbor’s house to get R1 while a staff member kept an eye on R1 from a distance. When staff arrived at the home & went to the property and could not immediately see R1. The owner waved him/her into the house, and he/she followed. R1 was sitting in the living room talking to him/herself. Staff walked R1 back to the van. R1 was transported home without further incident.”

Based on evidenced reviewed: On September 11, 2022. R1 can be seen enters a neighbors jumper and is unaccompanied. 6 minutes later, a staff member can be seen running towards the jumper, and escorted back to the facility.

On September 12, 2022. At 4:51 resident R1 appears in the video walking towards a neighbors deflated jumper. R1 can be seen walking on the asphalt without any shoes. R1 can then be seen walking towards the neighbors home. At 5:03pm, a van is observed arriving at the neighbors home. At 5:05pm, R1 is taken inside the van.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20220913094545
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: SYCAMORE HOME
FACILITY NUMBER: 435202728
VISIT DATE: 05/13/2025
NARRATIVE
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Based on a review of R1’s Individual Program Plan (IPP), dated June 13, 2022, under safety skills/disaster preparedness: “R1 has very limited safety skills and requires constant supervision…R1 does not have street safety or stranger danger skills…if he sees something that is interesting to him/her, he/she may wander off to explore.” R1’s IPP also states on page 13, “Staff will provide care and supervision of behaviorally related events and provide redirection…”.

Based on a review of R1’s Physician’s Report dated December 18, 2021, R1 cannot leave the facility unassisted.

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

A civil penalty of $250 is being cited for a repeat violation, for the following code section: 80078 Responsibility for Providing Care and Supervision (a), which was cited during a complaint investigation visit on April 3, 2025.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Director of Operations David Sandhu. A copy of the report was provided. Appeal Rights was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20220913094545
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: SYCAMORE HOME
FACILITY NUMBER: 435202728
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2025
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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ADM/Licensee stated to submit a Plan of Correction by the POC due date to train staff on providing care and supervision necessary to meet the residents needs. Once the training is complete, the Licensee agrees to submit copies of the training records to CCLD.
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Based on interviews conducted and records reviewed, resident R1 eloped from the facility unsupervised on September 11 & 12, 2022. This poses an immediate health, safety or 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: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6