435202754-5-7-2025-26-AS-KHOS-DGLMZG-20250512100306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202754
Report Date: 05/07/2025
Date Signed: 05/07/2025 11:58:52 AM

Unsubstantiated

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
10/01/2024 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20241001103255

FACILITY NAME:	PRIMAVERA GARDENS		FACILITY NUMBER:	435202754
ADMINISTRATOR:	MICHAEL ELSOUSOU		FACILITY TYPE:	740
ADDRESS:	16095 CHURCH STREET		TELEPHONE:	(408) 778-5683
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	20	CENSUS: 17	DATE:	05/07/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Medtech - Rachel Pearce		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff are physically abusing resident while in care
Staff are not serving resident food quantity necessary to meet their nutritional needs
Staff not ensuring that incontinent residents are kept clean and dry
Facility staff are not competent to provide the services necessary to meet the residents need
Facility is not administering medication per doctor's order

INVESTIGATION FINDINGS:

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On 05/07/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegations received. LPA met with Medtech Rachel Pearce and explained the purpose of today's visit. Administrator is not present on this day.

During the investigation, LPAs conducted interviews, collected and reviewed pertinent documents, and made observations. As a result of the investigation, LPAs could not prove or disporve these allegations took place. Documentation, observations, and interviews are contrary to what the allegations state. These allegations are unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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