435202950-3-12-2026-26-AS-RMAO-DS5RL5-20260313130634

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202950
Report Date: 03/12/2026
Date Signed: 03/12/2026 02:53:29 PM

Unfounded

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
02/10/2026 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20260210093456

FACILITY NAME:	ROXBURY ELDERLY CARE LLC		FACILITY NUMBER:	435202950
ADMINISTRATOR:	LI, TINGXIU		FACILITY TYPE:	740
ADDRESS:	515 ROXBURY LN		TELEPHONE:	(408) 809-6806
CITY:	LOS GATOS	STATE: CA	ZIP CODE:	95032
CAPACITY:	6	CENSUS: 3	DATE:	03/12/2026
		UNANNOUNCED	TIME BEGAN:	01:08 PM
MET WITH:	Noemi Velasquez		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff forced a resident in care to stay in a room.
Staff did not ensure that resident was provided an adequate amount of toiletries.
Staff made an inappropriate comment towards a resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with facility staff Noemi Velasquez (S1).

On 02/10/2026, the Department received a complaint with the above 3 allegations.

On 02/20/2026, the Department conducted an initial investigation visit.

LPA interviewed staff S1 and Administrator (ADM).

LPA toured the facility and R1's bedroom.

LPA requested resident R1's physician report and appraisal needs and service plan.
Continue on LIC9099-C. Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

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-20260210093456

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: ROXBURY ELDERLY CARE LLC	FACILITY NUMBER: 435202950
	VISIT DATE: 03/12/2026

NARRATIVE

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Staff forced a resident in care to stay in a room:
Staff did not ensure that resident was provided an adequate amount of toiletries:
Staff made an inappropriate comment towards a resident in care:

On 02/20/2026, LPA interviewed staff S1. S1 stated resident R1 was not forced to stay in his/her room. S1 stated R1 was provided necessary and enough toilet paper. S1 stated he/she did not hear Administrator making any comment on R1. S1 stated R1 was provided a commode in his/her room because R1 played with toilet paper with water for long time when R1 used restroom, and caused toilet pipe clogged. S1 stated R1 used restroom for showering and brushing teeth. S1 stated R1 can walk in the facility by himself/herself.

LPA interviewed Administrator (ADM) Tingxiu Li. ADM denied all the allegations. ADM stated the facility has the approval from R1's POA to place a commode in R1's room for R1's toileting. ADM stated R1 was provided enough toilet paper for his/her needs. ADM stated R1 played water and toilet paper in the restroom and caused the facility pipe clogged. ADM stated R1 has severe mental disorders. ADM stated he/she did not make any comment on R1.

LPA interviewed R1's Power of Attorney (POA). POA stated R1 had lived with him/her before for 25 years. POA stated R1 has severe mental disorders. POA stated R1 is unable to describe well on what he/she wants to express. POA stated R1 had some behaviors in the facility and caused serious problem to the facility. POA stated he/she agrees the facility to put a commode in R1's room for R1's toileting. POA stated all the allegations are not true. POA stated he/she took R1 to psychiatry doctor and to transfer R1 to a bigger facility which he/she thinks is better for R1. POA stated the facility did not have any physical abuse or mental abuse to R1. POA stated the facility does not have any problem.

Based on review of R1's appraisal/needs and service plan dated 11/3/2025 and 11/04/2025, R1 has severe mental illness, severe emotional problems, behavior of attention seeking, and has been in institutionalized care since the age of 4.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20260210093456

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: ROXBURY ELDERLY CARE LLC	FACILITY NUMBER: 435202950
	VISIT DATE: 03/12/2026

NARRATIVE

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The Department has investigated the above allegations. Based on the investigation, observation, records reviewed, and interviews conducted, the Department found that the above allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview conducted with S1. This report was provided to review and for signature. A copy of this report was provided to S1.

Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 3