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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600386
Report Date: 12/17/2024
Date Signed: 12/17/2024 02:21:40 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
12/13/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20241213161313
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: 3DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jezrael Pascual, Facility ManagerTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff are not providing food to residents in the quantity needed
Facility staff are not providing assistance to residents when needed
INVESTIGATION FINDINGS:
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On 12/17/2024 at 10:00am Licensing Program Analysts (LPAs) K. Nguyen and L. Alexander arrived unannounced to conduct investigation of the above allegations. LPAs met with House Manager, Jezrael Pascual informed the purpose of LPA's visit and requested to call to Administrator (ADM), Victoria Puruganan. ADM was not available during the time of investigation. ADM gave permission to Jezrael to sign the report.

Allegation: Facility staff are not providing food to residents in the quantity needed- Unsubstantiated

During the course of investigation, LPAs reviewed files and conducted interviews with residents/ staffs. LPAs observed three residents and three staffs at the facility. It was alleged that facility staff are not providing food to residents in the quantity needed. LPAs interviews two residents and attempted to interview the third resident. Two out of two residents’ states that the food is in good quantity. Two out of two residents’ states that they received three meals a day and snack.

Report continued on LIC 9099c…


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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-20241213161313
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: 12/17/2024
NARRATIVE
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Allegation: Facility staff are not providing assistance to residents when needed- Unsubstantiated

During the course of investigation, LPAs reviewed files and conducted interviews with residents/ staffs. LPAs observed three residents and three staffs at the facility. It was alleged Facility staff are not providing assistance to residents when needed, however LPAs interviewed residents two out of two indicated that staff are providing them with assistance they need, and when they needed. LPAs interviewed three staff 3 out of 3 stated they assisted residents with, bathing, changing, cooking, laundry,

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 is conducted and a copy of this report is provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2