435202921-12-4-2025-26-AS-RMAO-DQNVAF-20260125151553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202921
Report Date: 12/04/2025
Date Signed: 12/04/2025 04:30:11 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
10/28/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20251028084103

FACILITY NAME:	GLENGROVE RESIDENTIAL CARE HOME LLC		FACILITY NUMBER:	435202921
ADMINISTRATOR:	DUMANTAY, ERWIN		FACILITY TYPE:	735
ADDRESS:	3889 GLENGROVE WAY		TELEPHONE:	(408) 728-5505
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY:	6	CENSUS: 5	DATE:	12/04/2025
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Staff Riza Baruela		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Staff did not provide adequate supervision resulting in resident sustaining injury.

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 Staff Riza Baruela.

On October 28, 2025 the Department received a complaint alleging Staff did not provide adequate supervision resulting in resident sustaining injury. It has been alleged resident R1 sustained an injury on October 14, 2025.

On October 16, 2025, the Department received an incident report (IR) for resident R1. The IR stated on October 14, 2025, around 3:45pm a staff member as with R1 in his/her bedroom assisting with his/her care. R1 lost his/her balance and staff assisted and prevented a full fall. Staff member called out to other staff members to assist them both off the floor. Page 1 Out of 4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 26-AS-20251028084103

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: GLENGROVE RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 435202921
	VISIT DATE: 12/04/2025

NARRATIVE

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On October 15, 2025, the Department received an IR for resident R2. The IR 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 and R2 stuck staff members. Staff contacted local law enforcement and R2 was taken to the hospital.

On November 4, 2025, LPA Manuel Monter interviewed residents R4 and R5. Resident R4 stated he/she doesn’t remember what occurred on October 14, 2025 and was unable to provide any relevant information regarding the allegation. LPA attempted to interviewed resident R5, but R5 did not provide any responses to questions posed and did not provide any relevant information regarding the allegation.

LPA Manuel Monter interviewed staff S1-S6. 5 Out of 6 Staff (S1-S5) stated they were working on October 14, 2025 when R1 fell. S1 stated he/she was attending to resident R3 when R1 had fallen.

S3 stated around 3:40-3:50pm, he/she was transferring R1 from his/her bed to the family chair, R1 then slid and was being combative (hitting in a slapping like motion and trying to pull hair). S3 stated as R1 was falling, he/she managed to hold R1 so he/she didn’t fall. S3 stated he/she didn’t see R1 hit anything. S3 stated he/she called for assistance. S3 stated S2 tried to help but wasn’t able to assist, due to R1’s combativeness. S3 stated that staff S4 was able to get R1 up. S3 stated there was no injury noted on R1. S3 stated the following day, after the fall, they did notice a noticeable mark on R1’s face in the morning, which became more noticeable in the afternoon. S3 stated the same day, around 7:00pm, R2 did have a behavior. S3 stated he/she was not with R1 at the time. S3 stated R2 was upset with resident R3. S3 stated he/she was doing laundry at the time.

S2 stated around 3:30pm, he/she was preparing a meal for R1, when staff S3 called for help. S2 stated he/she and S4 went to go assist. S2 stated staff S3 couldn’t get R1 up because R1 was pulling and pushing S3. S2 stated he/she attempted to help R1, but R1 was being combative. S2 stated he/she asked staff S4 to help. S2 stated the same day, around 7:00pm, R2 was having a behavior, as he/she was in R1’s room. S2 stated as staff assisted R3 to the bathroom, R2 then attacked resident R3. S2 stated R2 was throwing things and trying to get “revenge” because R2 thought, R3 had yelled at him/her. Page 2 Out of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 26-AS-20251028084103

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: GLENGROVE RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 435202921
	VISIT DATE: 12/04/2025

NARRATIVE

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Staff S4, stated regarding R1’s fall, staff S3 called for assistance because R1 was falling and needed assistance. S4 stated he/she observed R1 was holding/pushing S3 and swinging his/her arms towards S3 and S2. S4 stated he/she assisted R1 to his/her chair. S4 stated he/she doesn’t remember R2 having behaviors on October 14, 2025.

Staff S5 stated he/she was in the dinning room when R1 fell and S3 called for assistance. S5 stated later that same day, around 7 pm R2 did have a behavior. S5 stated R2 was upset at R1 for being noisy. S5 stated R2 was banging on R1 door, but didn’t get inside. S5 stated he/she was following R2 as he/she was having his/her tantrum and redirected R2, when he/she was banging on R1’s door. S5 stated R2 had also gotten into an argument with R3 as well. S5 stated as he/she was redirecting R2, he/she was struck and another staff was also hit, because R2 was also throwing things. S5 stated staff had called the police for assistance due to the violent behavior. S5 stated R2 gets upset due to loud noises. S5 stated R2 did not get inside R1’s room.

5 out of 6 Staff (S1-S5) stated on October 14, 2025, they did not observe any residents hitting residents R1. Staff S6 stated he/she was not in the facility when the incidents occurred.

LPA Monter interviewed ADM Dumantay. ADM stated he/she was not at the home on October 14, 2025. ADM stated based on what he has been told, R1 had an assisted fall and may have hit his/her head on the way down or hit on the drawer or the chair.

ADM stated regarding R2’s behavioral outbreak, he also only knows based on what the facility staff have told him. ADM stated on October 14th, resident R1 was in his/her bedroom with a staff member. ADM stated R1 was making noises and was very loud. ADM stated R2 became upset due to the noise and began banging on the door of R1’s bedroom. R2 couldn’t enter because the door was locked. ADM stated staff intervened, and that was when R2 stuck staff and staff then contacted 911. ADM stated the police arrived and took R2 to EPS. ADM reiterated that the whole incident, R1’s bedroom door was closed the whole time.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20251028084103

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: GLENGROVE RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 435202921
	VISIT DATE: 12/04/2025

NARRATIVE

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On December 2, 2025, LPA Manuel Monter interviewed Witness W1. W1 stated he/she was became aware of R1 sustaining an injury on either October 14 or October 15th. W1 stated the facility had indicated that R1 had fallen from his/her bed. W1 stated the facility staff, approximately 1 week later provided a revised version of events, stating R1 crawled after falling, and hit his/her face on the cabinet. W1 reported that R1 does not like to be touched, and will resist care, and will push away / pull hair attempts when care is being provided. W1 stated that when R1 resists care, he/she does so without using significant force.

On December 4, 2025, LPA Manuel Monter interviewed residents R2, R3 and R6. Resident R2 stated he/she remembers what happened on October 14, 2025. R2 stated that day he/she didn't hit or throw things towards R1. R2 stated he/she didn't enter R1's bedroom. R2 stated he/she didn't see R1 fall. Resident R3 stated he/she does not remember what happened on October 14, 2025. R3 stated the police came to the facility and that he/she does not like the police. LPA attempted to interviewed resident R6, but R6 did not provide any responses to questions posed and did not provide any relevant information regarding the allegation.

The Department reviewed resident R1’s Appraisal Needs and Services Plan dated, October 8, 2025. The Appraisal states R1 has behaviors such as spitting at others, hitting, scratching, pushing, pulling hair, kicking, throwing objects at others. R1 also has self injurious behaviors such as slapping and hitting his/her face, rubbing face, scratching self, banging his/her head or pulling his/her hair. R1 is also resistive and uncooperative especially during personal care.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although R1 sustaining an injury is a fact, there is not a preponderance of evidence to prove that the allegation, neglect/lack of supervision did or did not occur.

This report was reviewed with ADM Erwin via phone call ADM stated he has a prior appointment and cannot come to the facility. ADM stated staff Riza can sign on his behalf.

Page 4 Out of 4. END OF REPORT.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

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