435202870-6-27-2025-26-AS-KHOS-DJDKPC-20250708080432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202870
Report Date: 06/27/2025
Date Signed: 06/27/2025 09:41:13 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
06/06/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20250606120507

FACILITY NAME:	DIGNITY CARE HOME		FACILITY NUMBER:	435202870
ADMINISTRATOR:	ANN MARIE R ZARRAGA		FACILITY TYPE:	735
ADDRESS:	3899 MARE PLACE CT		TELEPHONE:	(909) 205-0891
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY:	6	CENSUS: 6	DATE:	06/27/2025
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Administrator Ann Marie R Zarraga		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Staff does not provide a comfortable room temperature for residents.
Facility Staff threaten residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Ann Marie R Zarraga

On June 6, 2025, the Department received a complaint alleging Staff does not provide a comfortable room temperature for residents. .

On June 13, 2025, LPA Monter interviewed Witness W1. W1 stated on May 30th, 2025, it was too hot in the facility. W1 stated he/she didn’t have a way to measure the temperature in the facility. W1 stated he/she doesn’t know the temperature of the facility that day.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025

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 4

Control Number 26-AS-20250606120507

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: DIGNITY CARE HOME	FACILITY NUMBER: 435202870
	VISIT DATE: 06/27/2025

NARRATIVE

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On June 16, 2025, LPA Manuel Monter interviewed residents R1-R4. Resident R1, R2 were unable to provide answers to LPA's questions. Residents interviewed had behaviors such as not talking, ignoring questions, being distracted and engaging in other actions such as playing with toy/eating etc.

R3 stated he/she didn’t have a way of knowing how hot it was in the facility, when it was hot. R3 stated when it was hot inside the facility, the staff would close the blinds to stop the heat from coming in the home. R3 stated the staff also provided water and fans.

R4 stated there has been times when the home was really hot. R4 stated she doesn’t remember the details of when this happened. R4 stated the home did have fans, water and ice-cream when it was hot.

LPA interviewed staff S1-S4. Staff S1 stated there have been times when the home was hot, but they facility provides residents with water, fans and icecream. S2 stated the facility temperature is comfortable because the facility has air conditioning. S3 stated on May 30, 2025, the temperature outside was 93 degrees. S3 stated it was very hot. S3 stated the home did have fans running and residents were provide cold snacks and water. S4 stated the facility doesn't get hot inside, and there hasn't been any issue with the temperature inside the home.

LPA interviewed ADM. ADM stated ADM stated the day of the incident, the outside temperature was very hot. ADM stated she and her staff didn’t measure the temperature of the facility at the time. ADM stated At the time before the air conditioning, they had lots of fans. ADM stated they provided water to the residents. and had ice cream as well.

On June 27, 2025, LPA Monter interviewed resident R5 and R6. R5 stated the home does get hot sometimes. R5 stated when the home gets hot, the staff close the blinds, give him/her water, and turn on the fans. Resident R6 declined to be interviewed.

Based on a review of weather.com, on May 30, 2025, the temperature in San Jose was 95 degrees F- high, and 60 degrees F-low.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20250606120507

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: DIGNITY CARE HOME	FACILITY NUMBER: 435202870
	VISIT DATE: 06/27/2025

NARRATIVE

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On June 16 2025, LPA measured the facility temperature using a thermometer. The facility room temperature was measured at 75 degrees F in resident bedrooms and kitchen/living room.

On June 27, 2025, LPA measured the facility temperature using a thermometer. The facility room temperature was measured at 72 degrees F in resident bedrooms and kitchen/living room.

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 that the allegations did or did not occur.

Facility Staff threaten residents

On June 6, 2025, the Department received a complaint alleging Facility Staff threaten residents.

On June 06, 2025, the Department interviewed Witness W1. W1 stated on May 30th, 2025, he/she observed staff S1 grab a spatula and started hitting the counter to get residents to be quiet. W1 stated he/she observed a staff member telling a resident if he/she does not go to his/her room, he/she will not be able to contact his/her family member.

On June 16, 2025, LPA Manuel Monter interviewed residents R1-R4. Resident R1, R2 were unable to provide answers to LPA's questions. Residents interviewed had behaviors such as not talking, ignoring questions, being distracted and engaging in other actions such as playing with toy/eating etc.

Residents R3 and R4 stated they haven't heard or seen any of the staff make threats towards the residents. R3 and R4 stated they haven't heard or seen the staff threaten residents with a spoon.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250606120507

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: DIGNITY CARE HOME	FACILITY NUMBER: 435202870
	VISIT DATE: 06/27/2025

NARRATIVE

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On June 16, 2025 LPA interviewed staff S1-S4. All staff interviewed denied the allegation, stating staff do not make verbal threats to residents or threaten residents with a spoon.

LPA Interviewed ADM. ADM stated her staff do not make Verbal threats to the residents. ADM stated staff do not deny residents calls with their family, stating it would make them more agitated. ADM stated her staff denied threatening residents with a wooden spoon.

On June 27, 2025, LPA Monter interviewed resident R5 and R6. R5 stated he/she doesn't know anything about staff making threats. R5 stated he/she never heard about this. Resident R6 declined to be interviewed.

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 that the allegations did or did not occur.

Page 4 Out of 4. END OF REPORT

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025

LIC9099 (FAS) - (06/04)

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