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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600386
Report Date: 05/19/2022
Date Signed: 06/17/2022 08:10:23 AM

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
05/18/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20200518102326
FACILITY NAME:HARTNELL HOME CAREFACILITY NUMBER:
015600386
ADMINISTRATOR:PURUGANAN,VICTORIA C.FACILITY TYPE:
740
ADDRESS:2041 HARTNELL STREETTELEPHONE:
(510) 489-7290
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
05/19/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Victoria Puruganan, Administrator
Erlinda Kloulubak, Staff		TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff Member sexually assaulted other staff members in front of residents
Staff Member made residents of the facility shoplift
Staff Member hit residents while working in the care home
Staff failed to report as required
INVESTIGATION FINDINGS:
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Amended report
On 06/17/22, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to amend and redeliver the findings of above allegations. LPA met with staff (S1) and spoke to administrator on the phone who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit with S1 and administrator.

Allegation: Staff Member sexually assaulted other staff members in front of residents
Investigation Finding: SUBSTANTIATED
S2 confirmed that S1 made inappropriate sexual remarks towards her while on duty at the facility in front of residents. S2 rejected all of S1’s sexual requests. S3 reported that S1 had attempted to rape her, also while at the facility. Both staff reported the incidents to Union PD and filed reports were consistent with their interviews conducted by Agency staff. R1 reported being advised by another former caregiver not to go to staff quarters by herself if S1 was in that area. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the above allegation is substantiated.
Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
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 4
Control Number 15-AS-20200518102326
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: HARTNELL HOME CARE
FACILITY NUMBER: 015600386
VISIT DATE: 05/19/2022
NARRATIVE
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Amended report
Allegation: Staff Member made residents of the facility shoplift.
Investigation Finding: SUBSTANTIATED
The Department found that other staff reported to local police that residents were being forced to shoplift for S1. R1 confirmed S1 would make her, along with other residents shoplift. While on a shopping trip, R1 stated S1 made residents hide food on their person. R1 stated residents would steal for S1 because they did not want to get hit by S1. Based on IB investigator’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Allegation: Staff Member hit residents while working in the care home.
Investigation Finding: SUBSTANTIATED
S1 was witnessed by S2, S3 and R1 hitting residents while in care. S1 would hit the resident over the head with his hands. Staff disclosed abuse to Union City PD. Statements provided by staff and residents were consistent with reports made to Union City PD. Based on IB investigator’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Allegation: Staff failed to report as required
Investigation Finding: SUBSTANTIATED
Incidents of S1’s physical abuse of residents and shoplifting were not reported to CCLD as required. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC 9099-D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and a copy of report provided to Administrator via e-mail.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20200518102326
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: HARTNELL HOME CARE
FACILITY NUMBER: 015600386
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
CCR
87468.1(a)(1)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons
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By POC due date, Administrator agreed to submit to CCLD proof of in-service staff retraining on residents’ personal rights as identified in Section 87468.1 (a)(1) of Title 22 regulations.
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This requirement was not met as evidenced by staff sexually assaulting other staff at the facility in front of residents which posed a potential risk to clients in care
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Administrator submitted proof of in-service staff retraining on 6/10/22.

Deficiency cleared.
Type B
06/10/2022
Section Cited
CCR
87468.1(a)(3)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination
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By POC due date, Administrator agreed to submit to CCLD proof of in-service staff retraining on residents’ personal rights as identified in Section 87468.1 (a)(3) of Title 22 regulations
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This requirement was not met as evidenced by staff made residents to shoplift which posed a potential health & safety risk to clients in care.
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Administrator submitted proof of in-service staff retraining on 06/10/22.

Deficiency cleared.
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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20200518102326
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: HARTNELL HOME CARE
FACILITY NUMBER: 015600386
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
CCR
87468.2(8)
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To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse
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By POC due date, Administrator agreed to submit to CCLD proof of in-service staff retraining regarding clients’ personal rights as identified in Section 87468.2 (8) of Title 22 regulations.
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This requirement was not met as evidenced by staff hitting residents while working which posed a potential health & safety risk to clients in care
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Type B
06/10/2022
Section Cited
CCR
87211(1)(D)
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(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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By POC due date, Administrator agreed to submit to CCLD proof of in-service staff retraining on reporting requirements.
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This requirement was not met as evidenced by staff failing to report incidents as required which posed a potential health & safety risk to clients in care
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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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4