445294274-5-3-2024-26-AS-JJIN-D6ZU43-20240709151424

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294274
Report Date: 05/03/2024
Date Signed: 05/03/2024 11:19:00 AM

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
02/07/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240207103807

FACILITY NAME:	MAPLE HOUSE II, THE		FACILITY NUMBER:	445294274
ADMINISTRATOR:	CHEN, HONG-GEN		FACILITY TYPE:	740
ADDRESS:	2000 BROMMER STREET		TELEPHONE:	(831) 476-6366
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	40	CENSUS: 18	DATE:	05/03/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Administrative Assistant Rodilla Guerrero		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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A resident was inappropriately touched while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced investigation visit to deliver investigation finding and met with Administrative Assistant (AA) Rodilla Guerrero. AA called facility Administrator (ADM) Hong-gen Chen. ADM stated AA could sign on her behalf. LPA explained the purpose of the visit.

On February 7, 2024, the Department received a complaint alleging a resident was inappropriately touched while in care. It has been alleged that a man had touched the resident's private parts.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20240207103807

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: MAPLE HOUSE II, THE	FACILITY NUMBER: 445294274
	VISIT DATE: 05/03/2024

NARRATIVE

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On February 29, 2024, the Department interviewed Nurse N1. N1 stated that resident R1 was taking a medication that is supposed to have a calming effect but can also have the opposite effect, such as delusions, distortion and hallucinations. N1 stated on January 19, 2024, he/she visited R1 in person and stated there was no signs of sexual assault. N1 stated on February 5, 2024, R1 was also visited by a doctor and he/she found no signs of sexual assault.

On March 4 & 6, 2024, the Department interviewed resident R1. R1 was asked if anyone touched him/her in way that made him/her uncomfortable. R1 did not give a clear statement regarding if he/she was touched and didn’t not answer the question directly.

Based on a review R1’s Needs & Services Plan and Physician Report, R1 has a neurocognitive disorder and is confused/disoriented/ hallucinating.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

This report was reviewed with Administrative Assistant Rodilla Guerrero and a copy of the report was provided.

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END OF REPORT.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC9099 (FAS) - (06/04)

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