435202796-6-14-2024-26-AS-JJIN-D7FVUR-20240723164511

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202796
Report Date: 05/03/2024
Date Signed: 06/14/2024 12:55:37 PM

Unfounded

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
02/08/2024 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20240208125557

FACILITY NAME:	MADISON HOUSE LLC, THE		FACILITY NUMBER:	435202796
ADMINISTRATOR:	WANG, YING		FACILITY TYPE:	740
ADDRESS:	329 EL PORTAL WAY		TELEPHONE:	(408) 618-5389
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95119
CAPACITY:	6	CENSUS: 5	DATE:	05/03/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Hsiu Luan Liu		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Staff handled resident in a rough manner
Staff spoke inappropriately to a resident

INVESTIGATION FINDINGS:

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THIS IS AN AMENDED REPORT FROM COMPLAINT VISIT ON 05/03/2024. Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. LPA met with lead caregiver, Hsiu Luan Liu.

On 02/08/2024, the Department received a complaint alleging staff handled resident in a rough manner and staff spoke inappropriately to a resident. On 02/15/2024, the initial complaint investigation was conducted.

The following documents were obtained to include resident roster, 3 residents physician’s report and appraisal/needs and services plan, and correspondence.

SEE LIC9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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-20240208125557

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: MADISON HOUSE LLC, THE	FACILITY NUMBER: 435202796
	VISIT DATE: 05/03/2024

NARRATIVE

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On 02/15/2024, 3 residents were interviewed. 3 out of 3 residents denied a staff member handling the residents in a rough manner when performing activities of daily living (ADL) care. 3 out of 3 residents denied staff speaking to them in an inappropriate manner. 3 out of 3 residents denied staff yelling at the residents.

On 02/15/2024, 3 staff members were interviewed. 3 out of 3 staff denied staff handling the residents in a rough manner when performing ADL care. 3 out of 3 staff denied speaking to the residents in an inappropriate manner. 3 out of 3 staff denied yelling or raising their voice at the residents.

From 02/15/2024 – 02/22/2024, 3 witnesses were interviewed. 3 out of 3 witnesses denied the observation of staff handling the residents in a rough manger when performing ADL care. 3 out of 3 witnesses denied the observation of staff speaking to the residents in an inappropriate manner. 3 out of 3 witnesses denied the observation of staff yelling or raising their voice at the residents.

On 02/15/2024, LPA Dolores observed R1 at the facility. R1 was being assisted by staff during a meal. R1 was observed to be treated well by the staff with no observations of staff yelling, speaking inappropriately, or rough handling residents. R1 did not appear to be in discomfort or appear to be afraid of the staff. LPA did not observe any visible bruising on R1's skin.

Based on review of the police report records, on 02/08/2024 a welfare check was conducted at the facility for R1. R1 was deemed to be in good health and in well living conditions.

The Department has investigated the above allegations. Based on interview, record review, and observation the above allegation is unfounded meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with lead caregiver, Hsiu Luan "Tina" Liu and a copy of the report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC9099 (FAS) - (06/04)

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