011441172-4-29-2022-15-AS-KHOS-CEGHR2-20220516062447

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011441172
Report Date: 04/29/2022
Date Signed: 04/29/2022 06:20:03 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
02/09/2022 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20220209091853

FACILITY NAME:	ARLEEN'S RESIDENTIAL CARE #4		FACILITY NUMBER:	011441172
ADMINISTRATOR:	ARLENE S PUJANTE		FACILITY TYPE:	735
ADDRESS:	2097 DUVAL LANE		TELEPHONE:	(510) 780-0940
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	4	CENSUS: 3	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	05:45 PM
MET WITH:	Arlene Pujante/Administrator		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Facility retaining resident (R1) that requires a higher level of care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings on the above allegation. LPA met with Arlene Pujante, administrator, and informed the purpose of vist.

It was alleged that resident (R1) has been knocking on other home's doors stating that she is "being choked”, becomes agitated and aggressive resulting in the Hayward Police Department (HPD) being called and that HPD has responded to calls regarding R1 five or six times in January 2022. It was further alleged that R1 is allowed to roam about the neighborhood making false allegations and that R1 should not be retained in the facility and that R1 should be in a lockdown facility.

......continued next page (9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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-20220209091853

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 #4	FACILITY NUMBER: 011441172
	VISIT DATE: 04/29/2022

NARRATIVE

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During the course of investigation, LPA reviewed R1’s file and interviewed staff (S1, S2, S3, S4 and administrator), residents (R1 and R2) and R1’s case manager (CM). LPA also obtained copies of police reports.

Records revealed R1 has auditory hallucinations and has history of making false allegations but would later say the allegations are not true. Staff interviewed (S1,S2, S3 and S4) indicated that R1 had called the police in the past. Administrator indicated that R1 called the police on February 2022 but was not aware R1 called the police in January 2022. S4 stated R1 called the police twice in January and once in February. S2 and S3 indicated that R1 had called the police in the past due to hearing voices. R1 denied calling the police but police reports revealed R1 calling the police not 5 or 6 times but twice in January 2022. Police report only showed service calls.

R1’s Physician’s Report revealed R1 can leave the facility unassisted and independent with ADLs consistent with R1’s Individual Program Plan and Quarterly Monitoring Review. Records also showed R1 regularly sees psychiatrist and takes medications on consistent basis. R2 indicated she feels safe at the facility. CM indicated R1 can leave the facility unassisted, independent with ADLs and not a danger to self and to others. There’s no record showing R1 has been danger to self and others.

Based on all information obtained, although R1 had called the police on few occasions, R1 can leave the facility unassisted, independent with ADLs and is not a danger to self and/or others. Therefore, the allegation in unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

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