435202785-11-6-2023-26-AS-KHOS-CY8JB7-20231205055349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202785
Report Date: 11/06/2023
Date Signed: 11/06/2023 06:49:33 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
03/03/2023 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 26-AS-20230303161549

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:	04:00 PM
MET WITH:	Diosdado Arines		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was verbally abused and threatened by another resident
Resident was physically abused by another resident
Facility did not report unusual incident to required parties

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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

Regarding the allegation of resident was verbally abused, threatened, and physically abused by another resident, reporting party (RP) states that she heard resident (R2) calling R1 inappropriate names, RP states that R1's tone turned aggressive and heard shuffling over the phone.

LPA interviewed administrator and it was stated that R1 was in the room talking to someone when R2 yelled and told R1 to be quiet and called R1 “faggot”. There was no physical assault that happened during this time. Another staff (S1) was interviewed and stated that R2s behavior is yelling when other residents makes him/her uncomfortable. R2 also gets triggered by loud noises and starts calling people slurs when he/she notices loud noises. S1 also mentioned that RP came in to the facility but didn't ask anything regarding the incident that RP heard on the phone. S1 has become aware of the two residents having a verbal altercation and immediately separated them.

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-20230303161549

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegation of facility did not report unusual incident to required parties, RP arrived at the facility 15 minutes after the incident, where none of the staff reported the incident that had just occurred.

LPA interviewed administrator and it was mentioned that a special incident report (SIR) wasn't made for this incident because this is R2s baseline behavior, and the facility staff would make an SIR everyday if they had to write one every time R2 said swear words to staff or other residents. Before reporting incidents to Licensing or San Andreas Regional Center (SARC), administrator or staff need to investigate and know the reasons as to why the incident happened to get the story for all parties concerned.

Based on records review, part of the objective/plan for R2 is to be emotionally stable, minimize yelling, cussing, calling names to other people when angry. Control R2s physical aggression.

Therefore, based on the interviews conducted, files reviewed, and information collected, the above allegations are found to be UNSUBSTANTIATED, meaning that although the allegations 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