445202879-2-29-2024-26-AS-KHOS-D45J6E-20240408064613

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202879
Report Date: 02/29/2024
Date Signed: 02/29/2024 01:48:37 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
02/20/2024 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20240220080053

FACILITY NAME:	RACHELLE'S HOME III		FACILITY NUMBER:	445202879
ADMINISTRATOR:	ILAGAN, MYLA		FACILITY TYPE:	740
ADDRESS:	4101 FAIRWAY DRIVE		TELEPHONE:	(831) 201-4785
CITY:	SOQUEL	STATE: CA	ZIP CODE:	95073
CAPACITY:	26	CENSUS: 18	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Myla Ilagan		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator Myla Ilagan.

On 02/20/2024, the Department received a complaint with the above allegation. The Department received two photographs from a witness showing a leak near a pipe on the outside area of the facility.

During visit, LPA Marrufo observed two pipes, one black pipe along the wall on the exterior of the kitchen and another protruding from the ground. There was a puddle of water near the pipe on the ground that was about a foot long and 5 inches wide. LPA Marrufo observed a sandbag along the wall of an adjacent facility building and another two sandbags near the door of the same adjacent facility building.

See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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-20240220080053

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: RACHELLE'S HOME III	FACILITY NUMBER: 445202879
	VISIT DATE: 02/29/2024

NARRATIVE

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During visit, LPA Marrufo obtained a copy of an invoice from a plumbing company. The invoice is dated 12/27/2023. The Invoice states it is for labor and the installation of a pipe. The Invoice describes the work as “*ran snake cleaned kitchen drain, ran snake cleared tub pulled out hairs, raised up kitchen vent and put in line vent@ 4101 fairway dr.”

During interview, Administrator Myla Ilagan stated that water from the kitchen sink sometime overflows and pours from the pipe along the exterior wall. Then, the water will pour onto the ground. Administrator stated that she recalls that the plumbing company installed the black pipe along the exterior of the kitchen wall. Administrator stated to have notified the plumbing contractor afterwards via telephone that the pipe is still leaking, and the plumbing contractor visited the facility again briefly and stated that they needed to order more parts to fix the leak. Administrator stated the plumbing company did not leave any documentation of the last visit.

LPA Marrufo conducted a telephone interview with Plumbing Company Staff PC1, who stated that the plumbing company installed the longer black pipe on the exterior kitchen wall on 12/27/2023. PC1 stated to not have any documentation on a shorter pipe that the company had previously installed. PC1 stated to not have any documentation of a visit in which a plumbing contractor visited the facility and stated to need to order additional parts.

During visit, LPA Marrufo interviewed staff S1, who is a maintenance staff at the facility. S1 stated to have observed the leak occurring outside of the facility. S1 stated that the leak has been reoccurring. S1 stated that a plumbing company came to fix the leak “about a month ago.”

Page 2 of 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240220080053

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: RACHELLE'S HOME III	FACILITY NUMBER: 445202879
	VISIT DATE: 02/29/2024

NARRATIVE

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During visit, LPA Marrufo interviewed staff S2, who stated that the leaks have only occurred from the pipe along the exterior of the kitchen wall and not from the pipe from the ground outside of the facility. S2 stated that a plumbing contractor came to the facility and installed a short pipe along the kitchen exterior wall, but the short pipe still leaked when the kitchen sink overflowed. S2 stated the plumbing contractor visited again and installed the longer black pipe that is currently installed along the exterior of the kitchen wall. S2 stated the plumbing contractor instructed staff to remove the cap on the top of the black pipe to allow air to flow and push water down if the pipe is overflowing.

Based on information from interviews conducted with staff, and records reviewed, and observations made, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

LPA Marrufo requests an Action Plan by the facility which discusses how the facility plans to ensure that the leak outside of the facility kitchen will be fixed and how the facility will ensure the residents remain safe from the leak while repairs are ongoing. LPA Marrufo requests that the Action Plan be submitted within 7 days.

This report was reviewed with Myla Ilagan and a copy of this report was provided.

Page 3 of 3.

END REPORT

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

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