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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011441026
Report Date: 06/06/2022
Date Signed: 06/06/2022 02:11:32 PM

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
05/08/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20200508131152
FACILITY NAME:BROADWAY HOMEFACILITY NUMBER:
011441026
ADMINISTRATOR:DELEON, IMELDA F.FACILITY TYPE:
735
ADDRESS:6185 BROADWAY AVENUETELEPHONE:
(510) 894-3311
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:6CENSUS: 4DATE:
06/06/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Menchie Matalang, CaregiverTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
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9
Staff pushed resident.
INVESTIGATION FINDINGS:
1
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5
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13
On 6/6/2022 at 1:15PM, Licensing Program Analysts (LPAs), L. Hall and L. Fici arrived unannounced to deliver complaint findings for the allegation above. LPAs met with Menchie Matalang, Caregiver and explained the reason for the visit. LPA L. Hall spoke with Administrator, Imelda De Leon via telephone and approval was given for caregiver to sign documents.

During the course of the investigation LPA L. Hall interviewed staff. LPA was not able to interview Client 1 (C1) due to C1 no longer resides at the facility and whereabouts are unknown. LPA reviewed incident report 5/12/2020 which stated police arrived for incident that occured on 5/8/2020 and that C1 refused to do COVID protocols when returning to the facility. LPA did not receive any requested documents from facility.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
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-20200508131152
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: BROADWAY HOME
FACILITY NUMBER: 011441026
VISIT DATE: 06/06/2022
NARRATIVE
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Continued from LIC9099.

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.

Exit interview conducted and a copy of report was given
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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