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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600148
Report Date: 07/10/2020
Date Signed: 07/10/2020 01:10:44 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
02/06/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20200206114143
FACILITY NAME:ROSEGATEFACILITY NUMBER:
015600148
ADMINISTRATOR:MARYCHRIS DAVISFACILITY TYPE:
740
ADDRESS:1345 CLARKE AVENUETELEPHONE:
(510) 483-0150
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:40CENSUS: 20DATE:
07/10/2020
UNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Katie Wrobel, Licensee/AdministratorTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Mold in facility
Administrator not on premises of facility for sufficient amount of hours.
INVESTIGATION FINDINGS:
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On 7/10/20 at 11:24 AM, Licensing Program Analyst (LPA) D Panlilio conducted a Facetime video conference with Licensee/Administrator in order to deliver findings on the above allegations. LPA explained due to the present COVID 19 shelter in place order by the Governor issued on March 17, 2020, this complaint investigation is being conducted via Facetime tele-visit. Administrator was not physically available to sign this report due to COVID 19 shelter in place order.

On 02/11/20, LPA interviewed maintenance director regarding the allegation of mold at the facility. He stated that on 05/24/19, a mold analysis was done on Rooms # 10 & 19, Dining & Activities Room. The results came back then that there were spores present in these rooms.

Continued on next page LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
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-20200206114143
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: ROSEGATE
FACILITY NUMBER: 015600148
VISIT DATE: 07/10/2020
NARRATIVE
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On 05/2019, facility resolved the presence of mold spores by conducting periodic HVAC filter cleanings on all units inside the facility to ensure proper ventilation is taking place.

On 02/11/20, LPA toured the dining area, activities room and Room#10 along with the maintenance director to check for mold. LPA did not observe any mold in the dining, activities room and Room#10 bedroom/bathroom areas.

During visit, LPA conducted interviews with staff regarding ADM1's working hours at the facility. Staff told LPA that ADM1 was there at least 20 hours per week from 03/01/19 until 12/17/2019 to help Licensee organize facility's files and documents. LPA observed ADM1's work schedule could not be confirmed since the personnel record (LIC 500) was not available due to Licensee's claim that the former administrator (ADM2) stored all facility documents in a laptop that she could not access.

Based on prior interviews and record reviews conducted on 02/11/20, LPA found that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are unsubstantiated.

Due to COVID 19 shelter in place order, exit interview conducted via Face time tele-visit and a copy of this report provided to Licensee/Administrator via email.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
LIC9099 (FAS) - (06/04)
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