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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011441025
Report Date: 12/20/2024
Date Signed: 12/20/2024 02:17:48 PM

Substantiated


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
08/26/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240826093259
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: 4DATE:
12/20/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Jackelyn ManaloTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Facility did not report the client's medical non-compliance resulting to hospitalization
INVESTIGATION FINDINGS:
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On this day at around 1:20pm, LPAs Luisa Fontanilla and Patricia Manalo arrived unannounced to deliver finding on the above allegation and met with Jackelyn Manalo. LPAs explained to Manalo the purpose of the visit. The Administrator was informed about the purpose of the visit.

During the course of investigation, LPA conducted 10-day visit and interviewed the Administrator and staff 1 (S1) and obtained records of Client 1 (C1).
Based on interview conducted with the Administrator, C1 has self-injurious behavior (SIB-skin picking). Administrator states C1 was observed with marks on elbows and hand. C1 was admitted to the facility on 4/10/2024.
continuation on Lic 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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 5
Control Number 15-AS-20240826093259
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: 12/20/2024
NARRATIVE
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Below is the summary of doctor/hospital visits C1 had per the Administrator:
• On 4/24/2024, C1 was sent to ER for wound care.
• On 5/15/24, C1 had a follow up visit for wound care.
• On 6/26/24, C1 had a doctor appointment for wound care but refused to get out of the car
• On 6/27/24, C1 was in the hospital until 7/3/24 for wound treatment.
• On 7/8/24, C1 was sent to hospital and D/C back to the facility.
• On 7/10, C1 was sent back to the hospital due to worsening wound then transferred to skilled nursing facility.
Based on information provided by the Administrator, C1 declined to get wound treatment on 6/26/2024. The Administrator states C1’s Case Manager (CM) was informed about C1’s refusal to see the wound doctor for treatment. When asked by LPA if there is any documentation to show CM was informed, the Administrator was unable to provide LPA any proof.

On 8/27/2024, LPA interviewed S1 who states C1 was observed rubbing elbow on the edges of the table and side of the bed. S1 states that C1 refused to see the doctor for wound treatment twice but does not remember the exact dates.

On 12/12/2024, LPA interviewed S2 who states that S2 accompanied C1 in going to the doctor twice but does not remember exact dates. S2 states that during the first visit, C1 was already inside the doctor’s office waiting for the doctor when C1 ran out of the office and refused to go back to see the doctor. During the 2nd visit, S2 states C1 refused to get out of the Uber vehicle. Upon arrival at the doctor’s office.

On 8/26/2024, LPA interviewed C1’s Case Manager (CM) and family member to verify if the facility sent notification about C1’s refusal to go see the doctor. Both CM and family member denied getting notification from the facility about C1’s refusal to see the doctor for wound treatment. C1’s family member states a notification was received from the facility to inform that C1 was being sent to the hospital again due to swelling of the arm in July 2024.

Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D.

Exit interview was conducted with Manalo and Appeal Rights was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/26/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240826093259

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: 4DATE:
12/20/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Jackelyn ManaloTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Administrator provided client's family false information
INVESTIGATION FINDINGS:
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On this day, LPAs L. Fontanilla and P. Manalo arrived unannounced to deliver finding on the above allegation and met with Jackelyn Manalo. LPAs explained to Manalo the purpose of the visit.
During the course of investigation, LPA conducted interviews and record reviews.
On 8/27/2024, LPA interviewed the Administrator. He states that C1 has self-injurious behavior (SIB) and has history of biting right hand. He added that upon move in, C1 was observed with marks on elbows and right hand.

The Administrator provided LPA with a text message dated 7/8/2024 notifying C1’s family member about C1 being sent to the hospital again due to worsening wound.

continuation on Lic 9099A
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240826093259
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: 12/20/2024
NARRATIVE
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The Administrator denied providing false information to C1’s family member or to anybody.

LPA interviewed Staff 1 (S1) who states that C1 was observed rubbing right hand against the side of the dining table and side of the bed from time to time. S1 states staff would remind C1 not to rub hand against the table and bed.

A review of C1’s IPP indicates that C1 has self injurious behaviors.

Based on interviews and record review conducted, 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 noted.

Exit interview was conducted with Manalo and a copy of this report was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20240826093259
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2024
Section Cited
CCR
85072(b)(2)
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85072(b)(2) Personal Rights
(b) The licensee shall insure that each client is accorded the following personal rights.
(2) To have the facility inform his/her relatives and authorized representative, if any, of activities related to his/her care and supervision, including but not limited to notification of any modifications to the needs and services plan.

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The Administrator will review section cited and submit self-certification of understanding and statement indicating that the facility will ensure that responsible persons will be notified in case of any unusual incidents.
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This requirement is not met as evidenced by: Based on interviews conducted, facility did not notify C1's case manager regarding C1's refusal to go to doctor appointment for wound treatment.C1 was admitted to the hospital for sepsis.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5