<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600305
Report Date: 12/13/2023
Date Signed: 12/13/2023 01:29:24 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
12/08/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20231208142944
FACILITY NAME:ARLEEN'S RESIDENTIAL CARE FACILITY #5FACILITY NUMBER:
015600305
ADMINISTRATOR:NICHOLAS A MARCELOFACILITY TYPE:
735
ADDRESS:27784 ORMOND AVENUETELEPHONE:
(510) 670-2855
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:6CENSUS: 3DATE:
12/13/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Nicholas Marcelo, AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit client in care
Staff do not ensure client in care is adequately supervised
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/13/23 at 11:30 am, Licensing Program Analyst (LPA) Daisy Panlilio arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA spoke with Niko Marcelo, Administrator (ADM) and explained the purpose of the visit. LPA observed 3 clients (R1, R2, R3) while at the facility.

During investigation, LPA collected the following documents from ADM during visit: Personnel record, Clients Roster, resident (R1) admission agreement, functional assessment, needs & services appraisal, ISP/IPP plans and medication administration records.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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-20231208142944
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 FACILITY #5
FACILITY NUMBER: 015600305
VISIT DATE: 12/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During investigation, LPA interviewed staff (ADM, S1, S2) and resident (R1). Staff denied hitting any client at the facility. ADM stated that all staff are trained and certified direct service professionals (DSP II's) under the Regional Center of the East Bay (RCEB) program. ADM stated there are no 1:1 client at the facility. Staff stated they provide care and supervision to clients by assisting them with their activities of daily living, monitoring their whereabouts every 2 hours, giving clients their prescribed medications and providing them with nutritious meals every day.

LPA interviewed R1 who stated that staff treats him well and never hit him. R1 stated staff always assist him with his medications, prepares food for breakfast, lunch and dinner and cleans his room. R1 confirmed with LPA that staff does not yell or scream at him.

LPA was not able to interview R2 because he was attending the adult day program during visit. LPA tried to interview R3 who refused to answer any questions and walked away.

LPA also reviewed R1's functional assessment report dated 4/20/23 which showed that R1 is able to bathe and shower without help, dresses self completely, uses toilet by self, has complete bowel control, feeds self completely, handles his own personal hygiene, has no vision problems, no hearing loss, expresses self verbally, walks well alone and can leave the facility unassisted.

Based on LPA interviews and observations we have found that the complaint is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2