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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202918
Report Date: 07/31/2026
Date Signed: 07/31/2026 11:22:51 AM

Substantiated


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
07/13/2026 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20260713113340
FACILITY NAME:UMBRELLA RESIDENTIAL CAREFACILITY NUMBER:
435202918
ADMINISTRATOR:VALLARTA, ANABELEN D.FACILITY TYPE:
740
ADDRESS:4623 MANGRUM DRIVETELEPHONE:
(510) 709-7078
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY:6CENSUS: 5DATE:
07/31/2026
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Anabelen VallartaTIME COMPLETED:
09:50 AM
ALLEGATION(S):
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Facility is not arranging, or assisting resident, for medical and/or dental care appropriate wherein resident missed his/her appointments.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator (ADM) Anabelen Vallarta and stated the purpose of today’s visit.

On 07/13/2026, the Department received a complaint with the above allegations. On 07/13/2026, the Department conducted an initial investigation at the facility.

It was alleged that resident (R1) had a medical appointment on 07/10/2025 which was missed by facility staff.

Continuation on LIC 9099-C, Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026
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-20260713113340
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: UMBRELLA RESIDENTIAL CARE
FACILITY NUMBER: 435202918
VISIT DATE: 07/31/2026
NARRATIVE
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Page 2 of 2.

On 07/13/2026, LPA Rai and Licensing Program Manager (LPM) Romeo Manzano conducted an interview with Administrator (ADM) Anabelen Vallarta. ADM stated resident (R1) had a scheduled appointment on 07/10/2026 which R1’s Power of Attorney (POA) informed ADM about three weeks prior to the appointment. ADM stated she forgot about the appointment after ADM had noted the medical appointment on the facility calendar. ADM stated the appointment was for 07/10/2026 and ADM called R1’s medical office to reschedule the appointment for a later date in the month.

The Department has investigated the above allegation. Based on interview, record review and observation of the above allegation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated.

Deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Administrator, Anabelen Vallarta and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20260713113340
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: UMBRELLA RESIDENTIAL CARE
FACILITY NUMBER: 435202918
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2026
Section Cited
CCR
87456(a)(2)
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87465 Incidental Medical and Dental Care (a)(2) The licensee shall provide assistance in meeting necessary medical and dental needs…
This was not met as evidenced by:
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Administrator (ADM) stated to submit a written plan of action understanding regulations and ensuring facility staff provide assistance in meeting resident’s necessary medical needs by POC due date.
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Based on record review and interview, R1 was not provided assistance in meeting necessary medical needs wherein R1 missed their medical appointment due to ADM forgetting about the appointment which pose/posed a potential health, safety and/or Personal Right’s risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3