435202909-11-24-2025-26-AS-RMAO-DQNV2R-20260125150333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202909
Report Date: 11/24/2025
Date Signed: 11/24/2025 05:24:05 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
09/24/2025 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20250924082135

FACILITY NAME:	SERENITY RESIDENTIAL CARE HOME		FACILITY NUMBER:	435202909
ADMINISTRATOR:	MANIBUSAN, AVERY		FACILITY TYPE:	735
ADDRESS:	6071 EMLYN CT.		TELEPHONE:	(408) 439-0857
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	4	CENSUS: 2	DATE:	11/24/2025
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:			TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff speak to residents in an inappropriate manner.
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 complaint investigation. LPA met with licensee John Manibusan. Administrtor Avery Manibusan was not available a tthe time of the visit. LPA stated the purpose of the visit.

On 09/24/25, the Department received a complaint with the above allegations.
On 09/30/25, the Department conducted an initial investigation
On 11/13/25, the Department conducted interviews.

On 09/30/25, LPA conducted and interview with 3 staff (S1 to S3).
S1 stated he/she have not seen a staff be mean or disrespectful towards a resident. S1 stated it was the other way around. Resident (R1) is very disrespectful and verbally abusive towards staff.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025

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-20250924082135

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: SERENITY RESIDENTIAL CARE HOME	FACILITY NUMBER: 435202909
	VISIT DATE: 11/24/2025

NARRATIVE

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S2 stated R1 is disruptive at night and screams, exaggerates everything, is abusive towards his/her own parent, and is verbally abusive towards staff and other residents.

S3 stated that R1 has been to 4 other homes, and he/she would always find something wrong with the places he/she lived in and moved out.

On 10/07/25 – the Department interviewed R1s service coordinator (SC) for San Andreas Regional Center (SARC). SC stated that R1 came from 4 other homes. SC stated R1 has extreme aggression and excessive disruptive behavior that R1 is displaying at the facility. SARC is aware of R1s behavior and agrees with the facility’s decision to evict R1 within 30 days for the safety of the other residents at the facility.

On 10/27/25 – LPA received a call from witness 1 (W1), W1 stated that staff do not respect resident 1 (R1) and R1 was accused of verbally abusing staff of a different sex. W1 stated that R1 has turrets (undiagnosed) and can sometimes be perceived as disrespectful. W1 stated that R1 compares S3 to their parent. W1 states that S3 talks to R1 badly and dis-respected R1. W1 stated, “they have these specific things they will say that R1 was disrespectful towards the opposite sex.” W1 does not remember the times and dates that R1 was called to be disrespectful towards the different sex. W1 stated that staff would scold R1 every 2 or 3 days, or once in every 3 or 4 days, and will tell R1 they do not care to hear any more reasons why R1 is being abusive towards the different sex. W1 stated staff make fun of R1s religion. When asked how and when this happened, W1 cannot provide the time and the date when the incident happened.

On 10/31/25, W1 sent an email to LPA of audio recordings of conversation initiated by R1 and called LPA to ask if LPA heard how S3 called R1 a “demon.” LPA listened to the audio recording, multiple times and stated to W1 that upon hearing the audio, LPA did not hear the word “demon.” Nor did anyone disrespect R1 during the conversation.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20250924082135

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: SERENITY RESIDENTIAL CARE HOME	FACILITY NUMBER: 435202909
	VISIT DATE: 11/24/2025

NARRATIVE

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On 11/13/25, the Department continued with the investigation and interviewed 2 residents (R2 & R3) and 1 staff (S4). R2 stated that when R1 came to the facility, they thought R1 was good, after a few weeks R1 started to change and became “weird”. R2 stated that R1 was “driving everyone crazy.” R1 was going off every time, screaming and yelling at people. R2 stated that all residents and staff would tell and ask R1 to stop. R2 stated that he/she is happy at the facility, and all staff are nice.

R3 was interviewed and stated, “at first R1 was great then R1 started to pick a fight with R4.” R3 stated he/she likes living at facility all staff are great and respectful towards R3. R3 stated that R1 is the one being disrespectful towards staff by screaming at staff. R3 stated when R4 left, R1 would pick a fight with R3. R3 stated that R1 punched his/her TV inside R3s room.

S4 was interviewed and stated, R1 has no respect for S3 and R1 yells at S4. R1 would ask S4 to do things for R1 and if it’s not done right the way R1 wants it, R1 will yell at S4. S4 stated it needs to be the way R1 wants and when R1 says it. R1 also yells at his/her parent when the parent did not do what R1 wants the way R1 wants it. S4 stated that he/she did not witness or hear S3 be disrespectful towards R1. S3 reminds everyone to be healthy and respectful towards staff and residents alike.

Based on document reviews physician’s report (LIC 602) and appraisal needs and services plan (LIC 625) R1 has autism spectrum disorder (ASD), very intelligent and needs constant medical supervision. R1 can be well mannered, but often R1 is extremely aggressive. R1 was prescribed medication, however, refuses to take any prescription medication and takes pro re nata (PRN) as needed for pain or headaches.

Based on document review, R1 has had multiple incidents of aggressive behaviors towards staff and residents that was documented from the time R1 was admitted to the facility.

Based on observation, LPA observed that R2 and R3 get along well and has no issues. LPA observed R2 and R3 engaged in a conversation when LPA arrived at the facility on 11/13/25.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250924082135

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: SERENITY RESIDENTIAL CARE HOME	FACILITY NUMBER: 435202909
	VISIT DATE: 11/24/2025

NARRATIVE

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LPA inspected 4 resident bedrooms and found that R1 to R4 have their own room, R2 does not share a bathroom with the other residents. R1 and R3 share a bathroom in the hallway between R2 and R3s room. LPA observed a broken TV screen and shoe print on the door of R3s bedroom.

The Department investigated the complaint with the above allegations. Although the allegation 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 allegations are unsubstantiated.

No deficiencies were cited during today’s visit based on Title 22 of the California Code of Regulations (CCR). An exit interview was conducted with Licensee John Manibusan and a copy of the report was provided

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end of report

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025

LIC9099 (FAS) - (06/04)

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