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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202931
Report Date: 10/07/2025
Date Signed: 10/07/2025 04:57:42 PM

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
08/11/2025 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20250811095308

FACILITY NAME:LOVELY CARE HOMEFACILITY NUMBER:
435202931
ADMINISTRATOR:POWAR, JASVIR SINGHFACILITY TYPE:
735
ADDRESS:6487 HIDDEN CREEK DR.TELEPHONE:
(408) 766-1200
CITY:SAN JOSESTATE: CAZIP CODE:
95120
CAPACITY:6CENSUS: 6DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Reyna CarrascoTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff did not prevent resident from exposing self to neighbors while outside of the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Supervisor (S1) Reyna Carrasco.

On 08/11/2025, the Department received a complaint with the above allegation.

On 08/14/2025, the Department conducted an initial investigation visit.
LPA interviewed House Manager *HM), and 2 residents (R1, R2). LPA toured the facility inside and out with HM.

LPA requested LIC500, physician reports and appraisal needs and service of residents, house rule, residents sign out/sign in log.

Continue on LIC9099-C. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20250811095308
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: LOVELY CARE HOME
FACILITY NUMBER: 435202931
VISIT DATE: 10/07/2025
NARRATIVE
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Staff did not prevent resident from exposing self to neighbors while outside of the facility:

On 08/14/2025, LPA interviewed House Manager (HM). HM stated on 8/9/2025 around noon time, resident R1 went out to supermarket and R1 urinated outside of the facility when R1 was on the way home. HM stated R1 needed to go to restroom at that time and was unable to hold it. HM stated R1 urinated at a construction site and R1 faced to the fence. HM stated R1 did not face to the street when R1 urinated. HM stated a person with two kids passed by and observed the incident. HM stated a person came to the facility and knocked the door stating one of the facility residents had urinated outside and exposed. HM stated he/she went out to look at what happened and found R1 was walking back home. HM stated police officers came to the facility around 20 minutes later. And R1 was arrested by the police officers.

LPA interviewed resident R1. R1 stated on 8/9/2025, when he/she was walking back home from supermarket, he/she was urgent to use restroom. R1 stated he/she was unable to hold it at that time. R1 stated he/she chose a construction area to urinate. R1 stated he/she urinated at bush/tree and faced to the fence of the construction site. R1 stated after he/she urinated, a person walked by and yelled at him/her. R1 stated he/she did not intend to expose. R1 stated then he/she walked home.

R1 stated after he/she arrived at home, police officers came to the facility. R1 stated police officer arrested him/her and put him/her in jail for 5 hours. R1 stated then he/she was released to his/her family member. R1 stated his/her family member took him/her back to the facility. R1 stated police officers told him/her don't urinate on street any more.

Based on the interview and records reviewed, the facility staff did not observe R1's health condition change. The facility staff did not remind R1 to shorten the time period outside the facility or remind R1 to urinate before goes out.

Based on the records review, R1 was arrested for indecent exposure.

Citation noted today. See LIC9099-D.
Exit interview was conducted with S1. The report was provided fro review and signature. A copy of the report was provided to S1. Page 2 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20250811095308
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: LOVELY CARE HOME
FACILITY NUMBER: 435202931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2025
Section Cited
CCR
85076.4(a)
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Observation of the Client (a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning.

This requirement is not met as evidenced by:
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Administrator agreed to submit a plan of correction to prevent similar incident to happen again by the POC due date, and to provide staff training and submit the staff training log to CCL office.
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Based on interview and record review, the facility staff did not observe R1's condition change, and did not provide the necessary care and suggestion leading R1 urinated on street which poses/posed an 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.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5