011440602-1-10-2023-15-AS-KHOS-CN6R5W-20230117114348

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011440602
Report Date: 01/10/2023
Date Signed: 01/10/2023 09:09:14 AM

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
07/09/2021 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210709142555

FACILITY NAME:	GM RESIDENTIAL CARE HOME		FACILITY NUMBER:	011440602
ADMINISTRATOR:	CHILIN, GRICELDA G.		FACILITY TYPE:	740
ADDRESS:	4924 OMAR STREET		TELEPHONE:	(510) 226-0102
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	0	CENSUS: 0	DATE:	01/10/2023
		ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Griselda Chilin, Licensee		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Resident is being held at the facility against her will.
Staff are not allowing family member to take the resident on an outing.

INVESTIGATION FINDINGS:

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On 1/10/2023 at 9:00AM, Licensing Program Analyst (LPA) G. Luk arrived to deliver findings. LPA met with Licensee, Griselda Chilin.

During the course of investigation, LPA interviewed resident, staff, witnesses, and complainant. LPA reviewed and obtained documents including POA documents, restraining order, physician's report, emergency contact information, admission agreement, responsible party disclaimer, and visitation log.

In R1's admission agreement, W6 was the responsible party that admitted R1 into the facility. Physician's report dated 1/7/2021 states that R1 cannot leave the facility unassisted. Interview with resident revealed that resident can leave the facility and can have visitors.
(Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

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 15-AS-20210709142555

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: GM RESIDENTIAL CARE HOME	FACILITY NUMBER: 011440602
	VISIT DATE: 01/10/2023

NARRATIVE

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W2 signed a responsible party disclaimer indicating that W2 would assume responsible while R1 is outside of the facility. Visitor's log indicated that W2 have visited R1 at the facility. There was lack of information to support the allegation that staff are not allowing family member to take the resident on an outing.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

LIC9099 (FAS) - (06/04)

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