435201736-4-24-2025-26-AS-RMAO-DGVQ6R-20250521115354

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201736
Report Date: 04/24/2025
Date Signed: 04/24/2025 04:45:40 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
02/03/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230203135248

FACILITY NAME:	ABORN ADULT CARE HOME		FACILITY NUMBER:	435201736
ADMINISTRATOR:	DR. SHACY LEE RIVERA		FACILITY TYPE:	735
ADDRESS:	2868 ABORN ROAD		TELEPHONE:	(408) 223-1108
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	6	CENSUS: 6	DATE:	04/24/2025
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Administrator Arielle Teodoro		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff abused client in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Arielle Teodoro.

On February 3, 2023, the Department received a complaint alleging Staff abused client in care. Based on the information provided by the reporting party, S1 was seen physically abusing R1.

On January 30, 2023, Local Law Enforcement (LLE) responded to a reported incident that occurred on January 16, 2023. LLE noted during visit that R1 had a bruise on the back of his/her knee and left buttocks.

LLE interviewed S1. S1 stated he/she did not place any hands on R1.S1 stated that he/she did not know where the accusations are coming from. S1 stated he/she believed that accusation was from another staff with whom he/she had a verbal altercation. Furthermore, R1 was known to easily bruise.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

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 3

Control Number 26-AS-20230203135248

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: ABORN ADULT CARE HOME	FACILITY NUMBER: 435201736
	VISIT DATE: 04/24/2025

NARRATIVE

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LLE interviewed S2. S2 stated on the morning of January 16th, 2023, he/she was helping R2 change his/her clothes while R1 was sleeping in his/her bed. S2 stated S1 came into the room and flipped the mattress over and R1 fell to the ground. S2 stated S1 slapped R1 on both cheeks simultaneously and hit R1 on the top of the head. S2 stated S1 dragged R1 by the feet out of the room into the bathroom. S2 stated Once R1 dragged R1 to the bathroom, he/she left R1 alone in the bathroom. S2 stated he/she did not call the police because he/she did not know the phone number.

On February 7 & 9, 2023 and April 21, 2025, the Department interviewed staff (S1 to S6), 5 Out of 6 staff (S1, S3-S6) stated that they have never observed any staff abusing a resident, nor they have observed S1 abusing residents. 5 Out of 6 staff (S1, S3-S6) stated that they observed R1's bruising but they believed it was due to a fall and/or R1's behavior. Staff S1 denied the allegations that he/she physically abused R1.

S2 stated on the morning of January 16th, 2023, he/she was helping R2 change his/her clothes while R1 was sleeping in his/her bed. S2 stated S1 came into the room and flipped the mattress over and R1 fell to the ground. S2 stated S1 slapped R1 on both cheeks simultaneously and hit R1 on the top of the head. S2 stated S1 dragged R1 by the feet out of the room into the bathroom. S2 stated Once R1 dragged R1 to the bathroom, he/she left R1 alone in the bathroom.

The Department interviewed Licensee Teodoro (LN). LN stated she has never observed a staff abusing residents. LN stated staff are trained not to retaliate if a resident is aggressive and know how to redirect.

On April 24, 2025, LPA Monter interviewed residents R4 and R5. LPA attempted to interview R4, but R4 declined to be interviewed, and only murmured toward LPA, then covered his/her face using his/her blanket. Resident R5 declined to be interviewed. R5 stated he/she was going out with a staff

Based on the interviews conducted with residents (R1 to R4), R3 stated that he/she never seen any staff hit a resident, but he/she heard a bit of yelling and arguing between S1 and R1. R3 stated that S1 never hit him/her. Resident R2 and R4 are nonverbal and were unable to respond to LPA’s questions.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20230203135248

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: ABORN ADULT CARE HOME	FACILITY NUMBER: 435201736
	VISIT DATE: 04/24/2025

NARRATIVE

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Based on the interview with R1's sibling (SR), SR stated in an interview that her/his sister told him/her that the incident occurred at a school, and it was a male and female that assaulted R1.

Based on additional information gathered, R1 was non-verbal but was able to make connection with his/her sibling. R1's sibling asked him/her if the incident occurred at the facility or somewhere else. R1 was able to communicate with his/her sibling and advised the incident happened at a school and a male and female were involved.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are 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.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC9099 (FAS) - (06/04)

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