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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011405838
Report Date: 09/17/2021
Date Signed: 09/17/2021 03:51:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/29/2021 and conducted by Evaluator Allison O'Hollaren
COMPLAINT CONTROL NUMBER: 15-AS-20210629120541
FACILITY NAME:BETHESDA LUTHERAN COMMUNITIES-MOWRYFACILITY NUMBER:
011405838
ADMINISTRATOR:AVALON HENDERICKSFACILITY TYPE:
735
ADDRESS:1335 MOWRY AVETELEPHONE:
(510) 505-1245
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:12CENSUS: 12DATE:
09/17/2021
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Lead Direct Support Provider, Fidel De Castro TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff member had inappropriate interactions with resident
INVESTIGATION FINDINGS:
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On 09/17/2021 at approximately 2:55pm Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to conduct a continuing complaint investigation. LPA met with Lead Direct Support Provider, Fidel De Castro and explained the purpose of the visit.

During the course of the investigation, LPA interviewed seven residents (R1, R2, R3, R4, R5, R6, and R7), Area Director Antonio Duarte, and five staff (S1, S2, S3, S4 and S5). LPA reviewed & obtained physicians reports, IPPs, staff contact list, resident roster, incident report and internal investigation report. Based on interviews no individual indicated any knowledge of any instance of any inappropriate behavior.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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 2
Control Number 15-AS-20210629120541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BETHESDA LUTHERAN COMMUNITIES-MOWRY
FACILITY NUMBER: 011405838
VISIT DATE: 09/17/2021
NARRATIVE
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The Department has investigated this allegation and based upon interviews conducted and records reviewed, the allegation is found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation has occurred.

Exit interview conducted with Lead Direct Support Provider and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2