435202867-8-29-2025-26-AS-RMAO-DMEK44-20251013073345

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202867
Report Date: 08/29/2025
Date Signed: 08/29/2025 09:49:01 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
01/27/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20250127160004

FACILITY NAME:	WARNER HOME #2		FACILITY NUMBER:	435202867
ADMINISTRATOR:	GALLEON, ARMAND		FACILITY TYPE:	735
ADDRESS:	3068 FLORENCE AVE.		TELEPHONE:	(831) 917-2870
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	6	CENSUS: 6	DATE:	08/29/2025
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Staff Evangline Abela		TIME COMPLETED:	09:55 AM

ALLEGATION(S):

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Facility staff were lack of supervision resulting altercation between clients and leading to client sustaining injuries.

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 Staff Evangline Abela, who contacted Licensee (LN) Pam Sloan via phone call.

On January 27, 2025, the Department received a complaint alleging that facility staff’s neglect or lack of supervision led to a resident-to-resident altercation.

On January 31, 2025, the Department conducted an initial investigation visit. LPA interviewed Co- Licensee (LN) Pam Sloan and requested the resident’s physician report, appraisal of needs and service plan, progress notes, IPP, 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: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

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-20250127160004

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: 08/29/2025

NARRATIVE

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LPA Steve Chang and Simi Rai interviewed LN. LN stated on January 7, 2025, R1 and R2 had an altercation, where R2 scratched R1’s arm. LN stated staff separated R1 and R2 immediately. LN stated on January 20, 2025, R3 had an altercation with R1 in the van. R3 had scratched R1 and staff immediately intervened.

LN stated on January 29, 2025, the facility picked up R1 at his/her Family Members (FM) Home and found R1 had injuries on his/her body. ADM stated R1 expressed his/her family member (FM) assaulted him/her at home. ADM stated R1 never got injuries on the stomach at the facility. LN stated R1's Family Member (FM) never reported R1 obtaining any injury or physical abuse to her.

On August 19, 2025, LPA Manuel Monter interviewed residents R2-R6. 4 Out of 5 residents (R2, R3,R5, R6) did not respond to questions posed by LPA or provide any information regarding the allegations.

R4 stated R1 will sometimes hit by swinging his/her arms and will yell. R4 stated R1 will try to hit others once a month. R4 stated the staff will stop him/her if he/she tries to hit others. R4 stated R2 will scream but doesn’t know if R2 has ever hit others. R4 stated R3 will sometimes hit the staff. R4 stated he/she does remember when R3 grabbed and scratched R1. R4 stated, he/she, R3 and two other staff went to pick up R1 from his/her FM’s house. R4 stated R1 was upset and yelling. R4 stated when R1 entered the van, R3 reached over and grabbed/scratched R1. R4 stated staff was there and told R3 to stop. R4 stated he/she doesn’t remember clearly what happened after.

On August 13, 19 and 26, 2025, the Department interviewed Staff S1-S7. Staff S1 and S7 stated they were not present when the alleged altercations occurred on January 7, 2025 and January 20, 2025.

January 7, 2025
Staff S2 stated that morning he/she was mopping the kitchen. S2 stated he/she heard R1 yelling in the living room and when he/she entered he/she observed R1 was pointing at everyone. S2 stated he/she didn't see R2's hands on R1. S2 stated he/she saw S5 trying to redirect R1 to another activity.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250127160004

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: 08/29/2025

NARRATIVE

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Staff S3 stated he/she was making one of the residents beds when the incident occurred. S3 stated he/she didn’t actually see what happened. S3 stated he/she didn't hear any commotion that day. S3 stated when she finished her chores, she went to the living room. S3 stated Staff S5 and R1 told her what happened. S3 stated R1 showed him/her the scratch on his/her right arm.

Staff S6 stated that day he/she was in the kitchen to assisting in making breakfast. S6 stated he/she heard R1 was bothering R2, provoking him/her. S6 stated he/she went to the living room. S6 stated she observed R2 attempted to grab R1. S6 stated R2 didn’t actually grab R1, because of S5's intervention.

Staff S5 stated he/she knows he/she worked that day, but doesn’t remember any details. S5 stated he/she has no recollection. S5 stated typically, in mornings, staff will do the following: make breakfast, clean the bedrooms, mop and watch the residents. S5 stated he/she typically will wait in the living room, so when the transportation arrives, he check out clients with the driver and walk the residents to the van. S5 stated he/she doesn’t remember, but acknowledges that he/she was the person who filled out the progress notes detailing the event. S5 stated if R1 or R2 attempted to hit each other, he/she would intervene and redirect them to other activities.

January 20, 2025
Staff S3 stated they had finished a community outing and went to pick up R1 from his/her FM’s house. S3 stated he/she was in van, and S4 went to pick up R1. S3 stated R1 was upset and arguing with FM. S3 stated he/she was watching 2 clients in van while they had to convince R1 to enter the van. S3 stated when R1 got in the van, he/she was still upset, pointing at stomach and mom. S3 stated R1 is non verbal. S3 stated R3 maybe got upset because R1 was still talking and yelling. S3 stated when the van was moving, R3 grabbed R1. S3 stated R3 grabbed R1 and scratched R1. S3 stated when this happened, he/she told R2 to stop and R3 stopped.

S3 stated resident R4 was sitting in the front next to S4, the driver. S3 stated he/she was seated in the middle row, in the middle. S3 stated R1 was seated to his/her right.
S3 stated R3 was seated in the back, on the left side.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20250127160004

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: 08/29/2025

NARRATIVE

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S4 stated he doesn’t remember the exact details of what occurred on January 20, 2025. S4 stated he/she went to pick up R1. S4 stated R1 was upset with FM. S4 stated eventually he/she was able to convince R1 to enter the transport van. S4 stated R1 entered, was yelling, and staff tried to calm R1 down. S4 stated R3 grabbed/scratched R1 by the left shoulder. S4 stated he/she was still driving, when the incident occurred. S4 stated he/she needed to slow down the vehicle to a stop. S4 stated the other staff intervened and calmed down R1 and R3.

The Department reviewed an incident report dated January 7, 2025. The Incident report stated on January 7, 2025, at approximately 6:30am, R1 exited the restroom in an agitated state, yelling, pointing and flailing his/her arms. This behavior startled and upset resident R2 who was walking to the restroom and responded by grabbing R1 on his/her right forearm and right shoulder area. Care staff immediately intervened and redirected.

The Department reviewed an incident report dated January 27, 2025. The incident report also noted another incident that occurred on January 21, 2025, when residents were being transported. R1 began vocalizing loudly and flailing his/her arms, which caused distress to one of his/her other peers. In response, R3 grabbed R1 from behind by the shoulder and neck area, scratching him/her & Care staff immediately intervened.

Based on a review of R1’s Individual Program Plan (IPP), R1 requires support and redirection to manage inappropriate social behaviors such as yelling, screaming, inappropriate hand gestures, hitting, kicking and pushing others. R1 lacks safety skills and requires constant supervision from a responsible adult to ensure his safety during waking hours.

Based on a review of R2’s Individual Program Plan (IPP), R2 displays episode of aggression towards others seem to occur when R2 is upset. R2’s IPP states a reason for this aggression could stem from a noisy environment.

Based on a review of R3’s Appraisal Needs and Services Plan, dated May 13, 2024, R3’s care plan states, loud noises can affect R3, which has resulted in him scratching, pinching and grabbing people in the past. Note: the care plan does not note how the facility will curtail these behaviors.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20250127160004

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: 08/29/2025

NARRATIVE

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Based on a review of R2’s Appraisal Needs and Services Plan, dated March 20, 2024, R2’s behaviors include: hitting, pushing, spitting kicking, throwing items at others and pulling hair. Episodes of aggression seem to occur for reasons unknown when agitated or possible due to a noisy environment. Note: the care plan does not note how the facility will curtail these behaviors.

Based on a review of R3’s Individual Program Plan, dated May 23, 2022, R3 makes quite a bit of noise and is sensitive to noises. The noises will result in R3 scratching, pinching and grabbing people in the past. R3 will also have aggressive behavior such as kicking, pulling, grabbing, hitting, pinching and scratching. It has been reported that R3 in his/her past care home that he/she attacked a roommate that was sleeping. R3 requires supervision to prevent self harm and harm towards others.

Based on a review of R1’s Progress Notes dated October 30, 2024- January 30, 2025, at 6:20am R1 came out of the bathroom agitated, yelling, pointing and flailing his arms. R2 got scared and grabbed him.

On January 20, 2025, while in transport, R1 began loud vocalizations and flailing his arms. The behaviors disturbed his peer, R3. R3 scratched R1.

On January 29, 2025, R1 returned from a visit from FM. R1 had bruises on his/her stomach when he/she was picked up.

The department has investigated the above allegation. Based on the observations, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that neglect or lack of supervision led to a resident-to-resident altercation.

No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with Licensee Pam Sloan via phone call. LN stated staff Evangline Abela could sign on her behalf. A copy of this report was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

LIC9099 (FAS) - (06/04)

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