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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202961
Report Date: 08/25/2025
Date Signed: 08/25/2025 01:21:52 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
06/17/2025 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20250617094056
FACILITY NAME:ELLORE SENIOR LIVINGFACILITY NUMBER:
435202961
ADMINISTRATOR:AQUINO, JOYCEFACILITY TYPE:
740
ADDRESS:2350 CALLE DE LUNATELEPHONE:
(408) 755-6868
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY:303CENSUS: 27DATE:
08/25/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Executive Director, Slyvia ChuTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility did not ensure that resident is accorded dignity in their relationship with staff.
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 Executive Director, Slyvia Chu and stated the purpose of today’s visit.

On 6/17/2025, the Department received a complaint with the above allegation. On 6/23/2025, the Department conducted an initial investigation at the facility.

It was alleged the resident R1 was having a smoke break outside and tried to roll themselves in the street and facility staff did not assist and laughed at the resident.

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

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
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 2
Control Number 26-AS-20250617094056
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: ELLORE SENIOR LIVING
FACILITY NUMBER: 435202961
VISIT DATE: 08/25/2025
NARRATIVE
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Page 2 of 2.

On 6/23/2025, LPA Rai interviewed 1 staff (S1). S1 stated the incident occurred on R1’s first day at the facility 6/5/2025, where R1 was smoking in the front area of the facility and staff asked if R1 needed assistance but R1 was okay and self-propelled the wheelchair with the feet. S1 is not aware of staff not assisting or laughing at the resident.

On 6/23/2025, LPA Rai interviewed 1 resident (R1). R1 stated there were no issues with the incident that occurred on 6/5/2025. R1 stated he/she was smoking in the front area of the facility and staff asked if R1 needed assistance and R1 refused assistance. R1 stated no one was laughing at him/her and R1 has no issues with the facility staff. R1 stated the facility staff do protect his/her resident’s rights in the facility.

Based on review of R1’s pre-assessment dated 6/4/2025, R1 requires escorting and/or physical assistance to attend meals and/or activities due to using a wheelchair. R1 is generally oriented to person, time and place. Based on review of R1’s addendum to LIC 602A dated 6/2/2025, R1 does not have unsafe wandering, lack of hazard awareness or lack of impulse control and R1 is able to leave the facility unassisted.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the Department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Executive Director, Slyvia Chu and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2