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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202867
Report Date: 07/03/2025
Date Signed: 07/03/2025 09:19:51 AM

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
06/26/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240626075428
FACILITY NAME:WARNER HOME #2FACILITY NUMBER:
435202867
ADMINISTRATOR:GALLEON, ARMANDFACILITY TYPE:
735
ADDRESS:3068 FLORENCE AVE.TELEPHONE:
(831) 917-2870
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 6DATE:
07/03/2025
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Administrator Pam SloanTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Resident sustained injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced investigation visit to deliver the investigation finding and met with Administrator Pam Sloan

On June 26, 2024, the Department received a complaint alleging that a resident sustained an injury while in care.

On June 28, 2024, the Department conducted an initial investigation visit. The LPA interviewed the Administrator, staff, and residents, and requested the resident’s physician report, appraisal of needs/service plan, and incident reports.

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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
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 3
Control Number 26-AS-20240626075428
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: WARNER HOME #2
FACILITY NUMBER: 435202867
VISIT DATE: 07/03/2025
NARRATIVE
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On June 28, 2024, LPA interviewed Administrator (ADM) Pam Sloan, who stated that on June 18, 2024, staff noticed Resident R1 wearing a sweatshirt despite warm weather. Although staff suggested removing the sweatshirt, R1 refused, but reported feeling fine. Later, after an activity, R1 removed the sweatshirt, revealing a bruise on their left arm and side.

According to the ADM, staff notified her immediately, and she returned to the facility to assess R1. When questioned, R1 initially stated he/she injured themselves lifting the mattress, then revised the story to a bedroom fall, and finally to a bathroom fall. As R1 could not consistently explain the injury, the facility decided to send him/her to the hospital. R1 initially refused due to a family appointment but agreed after being offered a fast-food visit post-hospital. R1 was transported to the hospital around 1:30 PM and was discharged approximately 8:30 PM the same day.

ADM stated based on her internal investigation, R1 had fall in the bathroom. Three staff members were on duty during the night shift of June 17, 2024, and R1 did go to bathroom in the NOC shift. ADM stated R1 is able to use toilet by his/herself and has the right of privacy when using the restroom. ADM stated R1 did not report any incident on 6/17/2024 and 6/18/2024. ADM stated R1 did not report any incident on June 17–18, 2024, nor were any allegations of abuse received. ADM noted R1 has a history of fabricating stories.

On June 28, 2024, LPA interviewed 6 staff. 6 out of 6 staff stated they don't know what was the exact cause of R1's injuries and they did not see or hear any one physically abuse R1.

LPA interviewed 4 residents (R1 - R4). 3 out of 4 residents were unable to communicate or provide responses to questions posed by LPA. R1 confirmed no one hit him/her and that staff treated him/her well. R1 initially said he/she fell in the bedroom, then changed to a bathroom fall but could not recall date or time.

LPA interviewed R1's family member (FM). FM stated he/she does not know the exact cause of R1's injuries. FM stated he/she does not believe the facility staff abused R1. FM stated based on the conversation with the facility staff, he/she believes R1 had fall in the restroom.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20240626075428
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: WARNER HOME #2
FACILITY NUMBER: 435202867
VISIT DATE: 07/03/2025
NARRATIVE
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Based on the review of R1's physician report dated 6/10/2024, R1 left hand is with impairment. R1 is able to care his/her own toilet needs, and able to ambulate without assistance.

Based on the review of R1's appraisal needs and service plan dated 3/1/2024, R1 has limited use of left arm. R1 can toilet self independently.

Based on the review of R1's incident report, R1 had different stories for the incident when R1 was asked what happened about R1's injuries, R1 did not report the incident to staff because R1 did not want to mess up R1's appointment with family.

Based on the interview and record reviewed, R1 stated different stories for the injuries. R1 is able to use toilet independently. R1 has limited use of left arm to support R1's body balance if R1 loses balance and leaning to R1's left side. R1 denied that staff abused him/her. Staff stated no one saw or heard that R1 was abused by anyone.

Although it is a fact that R1 did sustain an injury while in care, based on a review of R1’s IPP and Needs & Services Plan, R1 is able to care for his/her own toilet needs. R1 is able to ambulate without assistance. Furthermore, Resident R1 stated he/she fell in the bathroom and denied being hit by anyone.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove neglect/lack of supervision did or did not occur.

Page 3 Out of 3. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC9099 (FAS) - (06/04)
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