435202848-2-16-2024-26-AS-RMAO-D2Q3EU-20240222171144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202848
Report Date: 02/16/2024
Date Signed: 02/16/2024 02:56:07 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
07/13/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230713102114

FACILITY NAME:	JADENS ARF LLC		FACILITY NUMBER:	435202848
ADMINISTRATOR:	PEREZ, JOCELYN		FACILITY TYPE:	735
ADDRESS:	5914 TANDERA AVENUE		TELEPHONE:	(650) 278-1110
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 5	DATE:	02/16/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Licensee Marilou Williams		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff physically abuse resident

INVESTIGATION FINDINGS:

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On 7/13/2023, the Department received an allegation of physical abuse of a resident (referred as R1) who sustained an injury on the abdomen by a staff.

Based on record reviews, although R1’s medical and facility documents indicate that R1’s injuries were caused by blunt force trauma and were severe requiring surgery, the origin of the injury could not be determined. There is no documentation recording bruising on R1’s torso.

Based on interview statements of staff (referred as S1 and S2), facility documentation is consistent two staff who were present prior to and during R1’s shower, which is when R1 claimed that he/she was kicked by a staff.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

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-20230713102114

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: JADENS ARF LLC	FACILITY NUMBER: 435202848
	VISIT DATE: 02/16/2024

NARRATIVE

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During the time of the alleged assault, S1 was with another staff (S2) while administering care to R1. Interviews with other residents (R2 to R3) and staff (S2 to S3) stated they have not experienced or have witnessed abuse by staff directed at a resident.

Based on R1’s facility file review and interviews with R1’s responsible party and staff, R1 had self injurious behaviors and a history of not depicting an accurate origin of his/her injuries. R1’s medical records also had episodes of hallucinations. R1 is known to give nicknames to each staff member and diagnosed with mixed behavioral conditions that affect cognition and recognition of events, time, and place of incidents. R1 is not able to articulate the series of events based on his/her recollection.

Due to R1’s self injurious behavior, staff conducts a regular body check, twice a day.

Based on documentation's and interviews of staff and residents R1 is consistently happy when it is time for R1 to visit family and enjoys the time spent with family, R1’s behavior is consistent after visiting family by showing his/her displeasure of being back in the facility after each family visit.

The San Jose Police Department (SJPD) conducted an interview investigation with S1. S1 was cooperative. S1’s has worked with other facilities and have not received any complaint from other family members of residents he/she worked for. SJPD found no evidence that shows R1 was physically abused by S1.

There is no sufficient evidence to prove or disprove the allegation that abuse, or assault occurred. The preponderance of the evidence gathered and analyzed indicated that the allegation is not true, therefore, the allegation is UNSUBSTANTIATED.

This report was reviewed with Licensee Marilou Williams. A copy of the report was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC9099 (FAS) - (06/04)

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