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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011441025
Report Date: 02/25/2022
Date Signed: 02/25/2022 10:40:36 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
03/05/2021 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20210305085815
FACILITY NAME:ARLEEN'S RESIDENTIAL CARE #3FACILITY NUMBER:
011441025
ADMINISTRATOR:NICHOLAS MARCELOFACILITY TYPE:
735
ADDRESS:32302 CREST LANETELEPHONE:
(510) 477-6700
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
02/25/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Eufe Goodman, StaffTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Physical Abuse
INVESTIGATION FINDINGS:
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On 2/25/22, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived at the facility to deliver finding for the above allegation. LPA met with Eufe Goodman and explained the purpose of visit.

Due to the shelter in place directive of the Governor and telework policy of the Department, all interviews were conducted via video calls.
On March 9, 2021, LPA L. Fontanilla initiated 10-day investigation and interviewed 3 staff, 3 clients and a witness. LPA reviewed Client 1 (C1) Individual Program Plan (IPP), Physician's Report, Lic 500 and Roster of Residents. On May 25, 2021, LPA interviewed S4.
Based on records reviewed and interviews conducted, C1 has had many prior visits to the emergency room (ER) due to behavior issues. Witness interviewed by LPA L. Fontanilla states that there were no mark or bruises observed on C1 when responded to. On 3/9/2021, LPA interviewed 3 out of 4 clients.

....continued next page (9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
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-20210305085815
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: ARLEEN'S RESIDENTIAL CARE #3
FACILITY NUMBER: 011441025
VISIT DATE: 02/25/2022
NARRATIVE
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All clients interviewed state that they like living at the facility, staff are good and that they feel safe living in the home. All 3 staff interviewed denied that a certain “Michelle” works at the facility.

Based on interviews and records reviewed, the above allegation is unsubstantiated. 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.

There is no deficiency note

Exit interview conducted and copy of this report provided to

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2