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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201311
Report Date: 05/30/2025
Date Signed: 05/30/2025 01:15:49 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
07/23/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240723151818

FACILITY NAME:ROSSMORE A.R.F. HOMEFACILITY NUMBER:
435201311
ADMINISTRATOR:HELEN V. CARRANZAFACILITY TYPE:
735
ADDRESS:2955 ROSSMORE LANETELEPHONE:
(408) 531-9487
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 5DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrative Assistant Ernie ManaoisTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff are not ensuring that facility is free of pests
INVESTIGATION FINDINGS:
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On May 21, 2025 the Department received a complaint alleging Staff are not ensuring that facility is free of pests. It has been alleged that cockroaches have been observed in the facility kitchen, restroom and residents bedrooms.

On August 2, 2024, LPA Manuel Monter interviewed residents R1-R3. Resident R1 stated he/she has seen cockroaches in his/her room and in the kitchen. Resident R2 stated he/she has not seen any cockroaches or any other pests in the facility. R3 stated he/she has seen roaches inside the facility. R3 stated the roaches can be seen at night.

LPA interviewed staff S2. S2 stated the facility has had some issue with cockroaches. S2 stated its an issue in R1’s bedroom. S2 stated the facility is cleaning everyday to address the roach issue. S2 stated the facility also bought traps.
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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 26-AS-20240723151818
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: ROSSMORE A.R.F. HOME
FACILITY NUMBER: 435201311
VISIT DATE: 05/30/2025
NARRATIVE
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LPA interviewed Administrative Assistant (AA) Ernie Manaois. AA confirmed that there has been cockroaches and he bought the traps on June 20, 2024. AA confirmed that R1’s room also have sticky traps as well.

During the tour of the kitchen, LPA had observed a cockroach behind the facility stove.

On May 30, 2025, LPA interviewed resident R4. R4 stated he/she has not seen cockroaches or other pests inside the facility.

LPA interviewed staff S3. Staff S3 stated he/she has not seen cockroaches in the facility, for the past month. S3 stated he/she did see cockroaches in the home more than 6 months ago.

Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrative Assistant Ernie Manaois and a copy of the report was provided. Appeal Rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 26-AS-20240723151818
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: ROSSMORE A.R.F. HOME
FACILITY NUMBER: 435201311
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2025
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement was not met as evidenced by:
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ADM stated she will send a written plan of action on how she will ensure the facility is free from pests, such as cockroaches. ADM stated this plan will state how the facility will note how they will prevent pests, and address any future pest infestations.
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Based on observations and interviews conducted, the licensee did not ensure the facility was free of cockroaches. This poses an immediate health, safety and personal rights risk to residents in care.
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ADM stated she will send the written plan of action to LPA by POC date, May 31, 2025.
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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: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
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