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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202770
Report Date: 04/10/2025
Date Signed: 04/10/2025 01:16:16 PM

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
07/11/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220711083051
FACILITY NAME:A AND A RESIDENTIAL CARE HOME, INC.FACILITY NUMBER:
435202770
ADMINISTRATOR:FARAKESH, REZAFACILITY TYPE:
735
ADDRESS:1084 WALLACE DRTELEPHONE:
(415) 385-8900
CITY:SAN JOSESTATE: CAZIP CODE:
95120
CAPACITY:6CENSUS: 5DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Administrator, Jose Roberto BarbaTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Resident sustained an unexplained bruise while in care.
Staff did not provide proper care and supervision to meet resident's needs.
INVESTIGATION FINDINGS:
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On April 10, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator Jose Roberto Barba and explained the purpose of the vist.

Regarding the allegation, resident sustained an unexplained bruise while in care, according to the reporting party, it was observed that Client 1 (R1) had a bruise on his/her leg.

During the investigation, LPA interviewed the administrator and two staff members. The administrator and two staff members denied this allegation and indicated they have not observed any bruises on any clients in care. According to the administrator and staff, R1 has a behavior where he/she scratches himself/herself and picks at scars from biting himself/herself. R1 was not able to be interviewed as R1 is non-verbal. According to documents reviewed, On 7/6/22, the facility did a body check on R1 as he/she woke up around 5am. According to the two DSPs on shift, it was noted that R1 had a scratch on the upper leg. According to R1's IPP/Care plan, R1 has a behavior of biting, itching, and picking at his skin.

(continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cowan April
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
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 2
Control Number 26-AS-20220711083051
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: A AND A RESIDENTIAL CARE HOME, INC.
FACILITY NUMBER: 435202770
VISIT DATE: 04/10/2025
NARRATIVE
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Regarding the allegation, staff did not provide care and supervision to meet resident’s needs, according to the reporting party, Client 1 (R1) is not being appropriately supervised and is not being dressed properly as R1 was observed without shoes on.

Based on staff interviewed, they denied this allegation and indicated, all residents including R1 are provided with shoes. R1 wears specific shoes when going out of the house due to an irritation on R1's foot. In addition, staff interviewed stated that R1 has a behavior where he/she will wear shoes but throw it.

Based on interviews conducted and records reviewed, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed with Administrator and a copy is provided.
SUPERVISORS NAME: Cowan April
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2