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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202785
Report Date: 11/06/2023
Date Signed: 11/06/2023 06:44:58 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
12/30/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20221230092356
FACILITY NAME:AFRA RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202785
ADMINISTRATOR:ARINES, DIOSDADO EMMANUELSFACILITY TYPE:
735
ADDRESS:686 ARDIS AVETELEPHONE:
(408) 247-1101
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:6CENSUS: 6DATE:
11/06/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Diosdado ArinesTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident is being physically assaulted/abused by other resident while in care.
Resident is being harrassed by other resident while in care.
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 resident (R1) is being physically assaulted/abused and harassed by other resident (R2) while in care. There were reports where R1 was hurt due to R2 being angry.

Based on records review, there were incidents where both residents have hurt each other. Both residents have behavioral issues. R1 has bipolar disorder and depression, which may affect moods but is generally happy and easy going but may become angry and irritable. R2 has verbal and physical aggression when he gets agitated. These two residents are roommates, with R1 just moving in a month when the incidents started to happen.
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)
Page: 1 of 2
Control Number 26-AS-20221230092356
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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LPA interviewed Administrator and it was mentioned that both residents have different personalities. After discussing with both family members it was decided to move R1 to a different room. Staff has monitiored the changes since the move and it has sh.own good progress with regards to the behavior of both residents. LPA also interviewed RP and mentioned that the facility has addressed the issues for the incidents and that R1 is now doing well.

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)
Page: 2 of 2