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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202921
Report Date: 12/04/2025
Date Signed: 12/04/2025 04:32:02 PM

Document Has Been Signed on 12/04/2025 04:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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:GLENGROVE RESIDENTIAL CARE HOME LLCFACILITY NUMBER:
435202921
ADMINISTRATOR/
DIRECTOR:		DUMANTAY, ERWINFACILITY TYPE:
735
ADDRESS:3889 GLENGROVE WAYTELEPHONE:
(408) 728-5505
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
12/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:Staff Riza BaruelaTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation 26-AS-20251028084103. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Staff Riza Baruela. ADM stated he has a prior appointment, and staff Riza Baruela could sign on his behalf.

On October 15, 2025, the Department received an incident report for resident R2. The incident report stated on October 14, 2025, at approximately 6:50-7:00pm, R1 was exhibiting behaviors (yelling and making noise in his/her bedroom.) R2 exited his/her bedroom and approached R1’s bedroom, which was locked with R1 and a staff member inside. Upon finding R1’s room locked, R2 began banging on it and kicking the door, demanding the door be opened. Two staff members intervened attempting to redirect. During this intervention, R2 stuck staff members. In response staff members secured other residents in their bedrooms for their safety. R2 began throwing items from his/her bedroom toward R1’s room. Staff contacted local law enforcement and R2 was taken to the hospital.

On October 21, 2025, the Department received an incident report dated October 21, 2025. The incident report stated, R2 was discharged back to the facility. Attached to the incident report was an admission record from the hospital, which states, R2 “attacked residents and throwing items.”

On October 14, 2025, at approximately 7:53pm, local law enforcement responded to Glen Grove Residential Care Home. Staff S6 stated he/she received a phone call from staff at the care home stating R2 was hitting and striking staff members and other residents in the home. S6 stated R2 was throwing things at a resident in the restroom and also struck a staff member. Local law enforcement relocated resident R2 to hospital.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: GLENGROVE RESIDENTIAL CARE HOME LLC
FACILITY NUMBER: 435202921
VISIT DATE: 12/04/2025
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On November 4, 2025, LPA Manuel Monter interviewed staff S2. S2 stated he/she was in R1’s room, when R2 was having a behavior around 7:00pm. S2 stated as staff assisted R3 to the bathroom, R2 then attacked R3. S2 stated R2 was throwing things and trying to get “revenge” because R2 thought, resident R3 had yelled at him/her. S2 stated he/she later saw the aftermath and saw R3 had a bruise on his/her elbow.

On December 4, 2024, LPA Manuel Monter interviewed resident R2. R2 stated on October 14, 2025 he/she was upset because another resident yelled "shut up." R2 stated he/she was upset and hit that other resident. R2 stated he/she does not remember what time or who he hit, but confirmed he/she did hit a staff member and resident.

Based on interviews and records reviewed, the facility did not submit an incident report documenting the episode in which resident R2 exhibited a behavior/tantrum that resulted in R2 making contact with and hitting resident R3.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with ADM via phone call and Staff Riza and a copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/04/2025 04:32 PM - It Cannot Be Edited


Created By: Manuel Monter On 12/04/2025 at 02:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: GLENGROVE RESIDENTIAL CARE HOME LLC
FACILITY NUMBER: 435202921

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/11/2025
Section Cited
CCR
80061(b)(E)

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80061 Reporting Requirements (b) (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.

This Requirement was not met as evidenced by:
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ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will submit the plan of correction to LPA by POC due date December 11, 2025
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Based on interviews and records reviewed, the facility did not submit an incident report documenting the episode in which resident R2 exhibited a behavior/tantrum that resulted in R2 making contact with and hitting resident R3. This poses a potential health, safety or personal rights risk to persons 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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2025


LIC809 (FAS) - (06/04)
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