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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200793
Report Date: 03/12/2024
Date Signed: 03/12/2024 05:16:42 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
11/06/2023 and conducted by Evaluator Maria Partoza
COMPLAINT CONTROL NUMBER: 26-AS-20231106142050
FACILITY NAME:NIKKO'S RESIDENTIAL CARE HOME IIFACILITY NUMBER:
435200793
ADMINISTRATOR:VILLAREAL, MICHELLEFACILITY TYPE:
735
ADDRESS:5724 BLOSSOM AVETELEPHONE:
(408) 972-1792
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 2DATE:
03/12/2024
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Michelle VillarealTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Resident's bedroom closet has molds
Facility has an electrical outlet that does not have a cover which could pose imminent danger to residents.
Facility uses resident's closet for storage.
INVESTIGATION FINDINGS:
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On 3/12/2024 - Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to conclude the complaint investigation received on 11/6/2023. LPA Partoza met with theLicensee/Administrator, here in referred to as LIC/ADM, Michelle Villarreal and stated the purpose of today’s visit.

On 11/06/2023, the Department received a complaint with the above allegations. Based on the allegation, resident 1, herein referred to as R1 has mold inside the closet. The mold is located on the right side of the closet wall in R1's bedroom and electrical outlets behind the beds does not have plate and cover and looks dangerous and R1 does not have enough storage for personal belongings because boxes were piled up.

page 1 of 3 (continued to LIC 9099C).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
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 7
Control Number 26-AS-20231106142050
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: NIKKO'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435200793
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2023
Section Cited
CCR
80087(a)
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80087 (a) Buildings and Grounds. The facility shall be clean, safe, sanitary, and in good repair for the safety and well-being of clients, employees, and visitors (b) All clients shall be protected against hazards within the facility. The requirement was not met as evidenced by
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ADM will submit a plan of correction by the due date. The closet wall will be repaired and affected area replaced. Wall eletrical outlets will be addressed and repaired immediately.
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Based on observation mold was present in R1s closet located on right side of the wall. The affected area measured at 5ft high x 3ft wide, black and grey color, damp to touch & 2 electrical outlet missing face plate. This poses/posed a potential health, safety or personal rights risk to persons in care.
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ADM corrected the deficiency within 24 hours. ADM had a professional remove the affected area and replaced with a new dry.
Type A
11/15/2023
Section Cited
CCR
80087(d)
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80087 Buildings and Grounds (d) General permanent or portable storage space shall be available for storage of facility equipment and supplies. This requirement was not ment as evidenced by:
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ADM have corrected the deficiency on the same day.
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Based on observation and interviews, the closets in R1s bedroom and bedroom #2 is being used by the facility to store supply overflow, which poses/posed a 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: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20231106142050
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: NIKKO'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435200793
VISIT DATE: 03/12/2024
NARRATIVE
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On 11/15/2023, LPAs Marrufo and Partoza, inspected R1s bedroom located at the end of the hallway and observed that a mold black and gray in color, splotches and clusters of microscopic dots were present. The area was damp to the touch and has a faint musty odor. The affected area measures approximately 5 ft high x 3 ft wide on the right side of the closet wall. LPAs observed 12 to 13 brown boxes that measures approximately 2ft high x 3 ft wide by 2ft deep piled up that occupies two thirds of the closet space.

During inspection of R1s bedroom, LPAs observed two electrical outlets that were missing the cover plate . The first one was at the right side of the bedroom wall behind the bed with a fan plugged in. The 2nd electrical outlet was at the left side of the bedroom wall, behind the 2nd bed..

LPAs inspected bedroom 2 which was vacant at the time of the inspection. LPAs observed that bedroom 2 was free from clutter and maintained. LPAS inspected closet at bedroom 2, and observed 12 to 14 brown boxes that measures approximately 2ft high x 3 ft wide by 2ft deep piled up and linens were stored, the items occupied the entire closet.

LPAs inspected bedroom 1; bedroom 1 is shared by 2 residents herein referred to as R2 and R3. The bedroom was free from clutter and maintained. LPA inspected the closet, and observed R2 and R3s personal belongings are stored in the closet.

On 11/15/2023, LPAs interviewed 3 staff , here in referred to as S1 to S3. S1 stated that he/she is aware of the mold in R1's bedroom and stated that the bedroom that R1 was occupying has been vacant for months.. S2 stated that he/she was not aware of the mold and stated that the room has been vacant for a number of months. S2 stated the facility currently has 2 residents who share one bedroom. S3 stated that he/she was not aware of the mold in R1s bedroom because he/she does not go in the resident rooms. S1 to S3 stated that the facility has a maintenance person who handles the care and maintenance of the facility. S1 to S3 stated that the boxes inside the closet of bedroom 2 and bedroom 3 were supplies used by previous residents who have transferred or have left the facility.

page 2 of 3
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20231106142050
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: NIKKO'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435200793
VISIT DATE: 03/12/2024
NARRATIVE
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Continued from page 2

On 11/15/2023, LPAs interviewed administrator herein referred to as ADM. ADM stated that R1 is new in the facility. ADM stated R1 is staying at the facility temporarily. ADM stated that R1s bedroom was vacant and not used for months. The facility has a current census of 2 permanent resident and 1 respite. ADM stated that the boxes inside R1s closet was an overflow of supply used by former residents. ADM removed the boxes in R1s closet and the 2nd bedroom at the time of the visit.

Based on observation, interviews and documents reviewed., the Department has investigated the above allegation. the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiencies were cited during today's visit per California Code of Regulation (CCR) Title 22.

Exit interview was conducted with the administrator Michelle Villarreal and a signed copy of the report with the appeals right was provided.

End of Report

page 3 of 3

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7