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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011440834
Report Date: 08/17/2020
Date Signed: 08/17/2020 03:08:20 PM



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
02/11/2020 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200211085628
FACILITY NAME:ST. REGIS RETIREMENT CENTER, INC.FACILITY NUMBER:
011440834
ADMINISTRATOR:CHINIKAMWALA, SHABBIRFACILITY TYPE:
740
ADDRESS:23950 MISSION BLVD.TELEPHONE:
(510) 881-7888
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:194CENSUS: 69DATE:
08/17/2020
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Shabir Chinikamwala, Executive DirectorTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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9
Facility failed to safeguard residents’ belongings.
INVESTIGATION FINDINGS:
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On 08/17/2020, Licensing Program Analyst (LPA) T. White called the facility to deliver the complaint findings for the above allegation. LPA spoke with Executive Director, Shabbir Chinikanwala. LPA explained due to the present shelter in place order by the Governor, the notification of the complaint is being done over the phone.

During the course of investigation, LPA conducted interviews and collected documentation in relation to the complaint. On Admission Agreement, Resident #1 (R1) resided in independent living. During interview conducted with Staff #1(S1) it was stated the facility has a licensed portion, assisted living, and unlicensed portion, independent living. S1 stated that R1 resided in the independent living portion. However, according to CCLD records it is unclear that the independent living portion is licensed by CCLD.

CCLD will conduct follow-up inspection regarding the facility at a later time.

Report continues on 9099C>
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2020
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 2
Control Number 15-AS-20200211085628
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: ST. REGIS RETIREMENT CENTER, INC.
FACILITY NUMBER: 011440834
VISIT DATE: 08/17/2020
NARRATIVE
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Although the allegations 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 allegations are UNSUBSTANTIATED.

Exit interview conducted with Executive Director and a copy of report emailed to facility.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2