435202158-10-27-2020-26-AS-RMAO-BUTRFY-20201028125951

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202158
Report Date: 10/27/2020
Date Signed: 10/27/2020 10:22:19 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/28/2020 and conducted by Evaluator Joanne Roadilla

COMPLAINT CONTROL NUMBER: 26-AS-20200128115155

FACILITY NAME:	KRISTINE MANOR II, LLC		FACILITY NUMBER:	435202158
ADMINISTRATOR:	KIROS WOLDEGIORGIS		FACILITY TYPE:	735
ADDRESS:	1320 RIDGEWOOD DRIVE		TELEPHONE:	(408) 202-2157
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	6	CENSUS:	DATE:	10/27/2020
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Kiros Woldegiorgis		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Client was sexually assaulted by another client while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Complaint tele-visit via phone today to deliver investigation findings. The Department has suspended on site visits due to COVID-19 shelter in place order by Governor Newsom. LPA spoke to Administrator (ADM) Kiros Woldegiorgis.

On 1/30/20, LPA David Marrufo conducted an unannounced 10-day complaint investigation visit based on the allegation that a client (C1) was sexually assaulted by another client (C2) while in care. Copies of resident’s documents as well as staff and facility records were obtained.

On 2/6/20, the Department interviewed C1 who provided details of the encounter. Per C1, on 1/20/20, C1 and C2 were in the facility’s backyard smoking a cigar. When they finished smoking, they both walked inside the house. C2 gave C1 a hug and attempted to touch C1 inappropriately but that C1 was able to prevent C2’s attempt. C1 believed that C2 was trying to touch C1 inappropriately but was not 100% sure. Continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

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-20200128115155

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: KRISTINE MANOR II, LLC	FACILITY NUMBER: 435202158
	VISIT DATE: 10/27/2020

NARRATIVE

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C1 stated that this was the first time C2 attempted such an action and has never made any other sexual advancements towards C1. When the incident occurred, C1 stated that all clients were sleeping, and the staff were busy cleaning or preparing breakfast, so no one witnessed the incident and C1 never told anyone.

Also, on 2/6/20, the Department interviewed ADM who stated that C1 and C2 were roommates during the month of November 2019 and part of December 2019. ADM stated that C2 likes to hug people, that when ADM would see C2 at the facility, C2 would hug ADM but that C2’s hugs were not sexual. ADM also stated that ADM has never seen C2 hug, kiss or inappropriately touch C1 or the other clients. Per ADM, C1 and C2 got along fine and would often smoke cigarettes in the backyard together. ADM denied any arguments or disagreements between C1 and C2. ADM also denied knowing anything about C2 touching or attempting to touch C1 in a sexual way. ADM stated that C1 never mentioned anything to ADM or the staff about the allegation until 1/24/20 when a San Jose Police officer showed up at the facility looking for C1. It was then C1 disclosed to ADM what happened.

Based on interviews, although the allegation 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 during today's tele-visit. Report was discussed with and a copy sent to Kiros Woldegiorgis to sign and mail back to CCL. Appeal Rights provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

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