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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011440289
Report Date: 01/23/2020
Date Signed: 05/19/2020 10:51:10 AM



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
01/21/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20200121100031
FACILITY NAME:DIANA'S CARE HOMEFACILITY NUMBER:
011440289
ADMINISTRATOR:OLIVE MANALASTASFACILITY TYPE:
740
ADDRESS:27402 MANON AVETELEPHONE:
(510) 786-9982
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:32CENSUS: 30DATE:
01/23/2020
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Grace Aquino, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
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8
9
Resident sustained injury while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amendment of 9099 dated 01/23/20 per supervisor review.

On 01/17/20 at 0600 AM, S2 noticed R1's right black eye and bruise on her forehead. S2 immediately reported R1's condition to S1 and ADM. S1 & S2 stated that they did not notice any bruises or right black eye on R1 on 01/16/20 all day and night. R1 did not recall how or when she got her bruises/right black eye. The resident's roommate (R2) stated she is a light sleeper and did not witness R1 fall or hit her head in their bedroom.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.
Copy of amended report emailed to Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2020
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 4
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
01/21/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20200121100031

FACILITY NAME:DIANA'S CARE HOMEFACILITY NUMBER:
011440289
ADMINISTRATOR:OLIVE MANALASTASFACILITY TYPE:
740
ADDRESS:27402 MANON AVETELEPHONE:
(510) 786-9982
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:32CENSUS: 30DATE:
01/23/2020
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Grace Aquino, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not report injury of a resident to the responsible party
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amendment of 9099 dated 01/23/20 per supervisor review.

Facility staff followed the Emergency/ID notification information for R1 (see 812 for details).

Based on LPA's interviews & record reviews, this complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. No deficiencies cited during visit.

Copy of amended report emailed to Administrator.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20200121100031
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: DIANA'S CARE HOME
FACILITY NUMBER: 011440289
VISIT DATE: 01/23/2020
NARRATIVE
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5
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7
8
9
10
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12
13
14
15
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32
Based on LPA's interviews & record reviews, this complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. No deficiencies cited during visit.

Copy of amended report emailed to Administrator.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 15-AS-20200121100031
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: DIANA'S CARE HOME
FACILITY NUMBER: 011440289
VISIT DATE: 01/23/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Copy of amended report emailed to Administrator.

SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4