435202785-11-6-2023-26-AS-KHOS-CXZKWU-20231128071632

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202785
Report Date: 11/06/2023
Date Signed: 11/06/2023 06:41:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2022 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220412095538

FACILITY NAME:	AFRA RESIDENTIAL CARE HOME		FACILITY NUMBER:	435202785
ADMINISTRATOR:	ARINES, DIOSDADO EMMANUELS		FACILITY TYPE:	735
ADDRESS:	686 ARDIS AVE		TELEPHONE:	(408) 247-1101
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	6	CENSUS: 6	DATE:	11/06/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Diosdado Arines		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility did not follow resident's crisis plan.
Facility did not pick up resident after discharge.

INVESTIGATION FINDINGS:

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On 11/06/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with LPA met with Administrator, Diosdado Arines and explained the purpose of today's visit.

Regarding the allegation of facility did not follow the residents’ (R1) crisis plan, reporting party (RP) stated that R1 was placed on 5150 due to display of aggressive behavior. There is a plan that has been set up for these situations. R1 has a crisis team that should be called, however, the administrator skipped that step and called 911 instead.

LPA interviewed RP and it was mentioned that R1 was stable when placed in the facility. RP also mentioned that plan wasn’t followed and has devolved overtime. LPA interviewed the administrator, and it was stated that the facility followed the crisis plan provided by the behavior consultant. R1 has already attacked another resident during this time that’s why the administrator was prompted to call to 911 after the crisis team was called.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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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Control Number 26-AS-20220412095538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: AFRA RESIDENTIAL CARE HOME	FACILITY NUMBER: 435202785
	VISIT DATE: 11/06/2023

NARRATIVE

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Based on records review, there have been several incidents reported that has happened in the facility regarding R1s behavior. R1 has been verbally aggressive to facility staff and residents. R1 has also physically hit some residents. R1s crisis plan notes that to only communicate when R1 is calm. If there is imminent risk of serious injury, contact 911. Part of the facility’s Program Plan is that it will work as a team with social workers, parents, schools/day programs, and consultants identifying and developing plans to address resident behavioral issues. All behaviors and interventions will be documented on the data collection forms or in the ongoing notes. Staff will be instructed in the prudent use of Crisis Team and 911 personnel to contain unsafe behavior episodes.

Regarding the allegation of facility did not pick up resident after discharge, RP stated that the staff called facility to inform them that the client was ready for discharge. However, the administrator refused to pick up the client.

LPA interviewed administrator and it was mentioned that, around dinner time of the same day, R1 was being released. Administrator to them to put a hold first since he needed to talk to the residents to assess how they are doing. Residents at the facility were still scared and upset. Behavior consultant also advised to assess residents and R1 first before pushing fort with the release from Emergency Psychiatric Service (EPS). Administrator also called EPS after assessment and consultations to keep R1 for the night and see the following morning if he was stable. The following day another reassessment was done and residents in the facility had been debriefed, and then R1 was picked up from EPS.

Therefore, based on the interviews conducted, files reviewed, and information collected, the above allegations are found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed and copy is provided.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

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