435202907-12-29-2025-26-AS-RMAO-DQQSN9-20260127130111

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202907
Report Date: 12/29/2025
Date Signed: 12/29/2025 09:08:13 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
05/28/2025 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20250528082034

FACILITY NAME:	CALIFORNIA MENTAL HEALTH LLC		FACILITY NUMBER:	435202907
ADMINISTRATOR:	CISNA, DEREK		FACILITY TYPE:	772
ADDRESS:	14865 MARIE COURT		TELEPHONE:	(949) 836-6793
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY:	6	CENSUS: 4	DATE:	12/29/2025
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Joshua Fane		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff mismanages residents' medications.
Staff are not reporting incidents to the proper agencies
Staff are falsifying residents’ records
Staff do not treat residents with dignity or respect

INVESTIGATION FINDINGS:

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Licensing program analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver the findings of the above allegations and met with Joshua Fane. LPA stated the purpose of the visit.

On 05/28/2025, the department received a complaint regarding the above allegations
On 06/05/2025, the department investigated, collected documents and interviewed staff and clients. LPA Kabariti interviewed 5 staff (S1 to S5) and 5 clients (C1 to C5).

See LIC 999C
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025

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-20250528082034

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: CALIFORNIA MENTAL HEALTH LLC	FACILITY NUMBER: 435202907
	VISIT DATE: 12/29/2025

NARRATIVE

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Staff mismanages residents' medications.
Staff Statements S1 to S5: Clients generally self administer medications with staff assistance. Occasional refusals were noted, providers/prescribers are notified, and responsible party (RP) are informed. Most staff were unaware of any medication errors, except S5, who identified a dosage discrepancy during C1’s first week. The error occurred due to a mismatch between the prescription e-portal and the facility’s patient portal, resulting in C1 receiving 25 mg instead of 100 mg from 05/23/25–05/27/25. The correct dosage was confirmed and updated after consultation with C1’s provider. S5 acknowledged the oversight and noted that C1 has knowledge of the incorrect dosage and did not inform staff.

Client Statements C1 to C5: C1 stated there was confusion regarding dosage and tablet count and did not notify staff. Documentation shows C1 declined medication on 05/21. Other clients (C2–C5) reported consistent access to medication and no missed doses.

Document review confirmed that C1’s written order on 05/19/25 listed 1 tablet of 25 mg daily but an increase to 100 mg was noted without updating the official order form, contributing to the error.

Staff are not reporting incidents to the proper agencies.
Staff Statements S1 to S5: Staff reported that incidents are documented and communicated according to protocol. S1 stated all incidents are reported to the appropriate agencies, including CCLD, and responsible parties are notified of behavioral changes. S2 confirmed responsible parties are informed when clients request to leave. S3 indicated incidents are reported to the director, who then notifies agencies. S4 explained that medication discrepancies, such as dropped or missing pills, are logged and reported to the director. S5 stated medication errors are reported to the client’s provider and the director.

Client Statement C1 to C5: C1 alleged that an altercation involving two clients was not reported by staff. Other clients (C2–C5) reported no significant incidents, however, C5 noted a minor argument that resolved quickly.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20250528082034

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: CALIFORNIA MENTAL HEALTH LLC	FACILITY NUMBER: 435202907
	VISIT DATE: 12/29/2025

NARRATIVE

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Staff are falsifying resident's records.
Staff Statements S1 to S5: S1 to S5 stated no staff is falsifying any resident records. They stated documentation is completed accurately and according to protocol.

Client Statement C1 to C5: C1 alleged that multiple incidents were incorrectly recorded in his/her chart, including a note stating medication refusal when medication was not offered. C1 also indicated he/she had never accessed his/her chart before. Other clients reported no concerns: C2 was unaware of the option to review records and noted memory issues; C3 confirmed no inaccuracies; C4 requested access and was added to the email list; C5 did not need to review their chart.

Based on document review 5 out of 5 clients’ medication administration, appraisal needs and services plan, and physician’s report was obtained. No falsification of information was observed and signed by the client, case manager, medical provider and reviewed by the program administrator.

Staff do not treat residents with dignity or respect.
Staff Statements S1 to S5: S1 to S5 reported that clients are always treated with dignity and respect. S1 stated they have never observed staff behaving disrespectfully. S2 noted that even during client altercations, staff maintained professionalism did not respond negatively. S3 emphasized that clients are treated with compassion, while S4 and S5 highlighted positive feedback and strong rapport-building efforts among staff.

Client Statement C1 to C5: C2–C5 stated feeling respected, with C3 describing staff as “like family.” C1, however, expressed dissatisfaction, stated staff did not intervene during an altercation with two clients and did not assist with transportation afterward. C1 acknowledged not requesting use of the facility phone and confirmed that his/her responsible party (RP) advised continuing treatment at the facility.

Based on document review and interviews the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

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Continued to LIC 9099A

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025

LIC9099 (FAS) - (06/04)

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