015600467-5-26-2026-15-AS-BFOG-DVUT35-20260710142145

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600467
Report Date: 05/26/2026
Date Signed: 05/26/2026 12:05:16 PM

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
05/22/2026 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20260522084539

FACILITY NAME:	A-R RESIDENTIAL CARE FOR ELDERLY		FACILITY NUMBER:	015600467
ADMINISTRATOR:	BAUTISTA, ROMULO		FACILITY TYPE:	740
ADDRESS:	4733 DARLENE COURT		TELEPHONE:	(510) 475-9058
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 5	DATE:	05/26/2026
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Alejandria Bautista, Assistance Administrator		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Staff refused resident re-entry to the facility

INVESTIGATION FINDINGS:

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On this day, 5/26/26 at 10:00 am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to investigate the above allegation and to deliver findings. LPA met with the Assistant Administrator, Alejandria Bautista. Administrator Romulo Bautista was not available during the visit. LPA explained the purpose of the visit via phone and received permission for Alejandria to sign the report.

Allegation: Staff Refused Resident Re-Entry to the Facility – Substantiated

During the course of the investigation, the Licensing Program Analyst (LPA) conducted interviews with Administrator Assistance and reviewed Resident 1 (R1) records, including, but not limited to, hospital discharge paperwork, facility records, admission agreement documents, and communication logs.
It was alleged that facility staff refused the resident re-entry after the resident’s discharge from the hospital on 5/23/26.

Report continued on LIC 9099c...

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

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-20260522084539

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: A-R RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 015600467
	VISIT DATE: 05/26/2026

NARRATIVE

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Report continued...

Interviews conducted during the investigation revealed that the R1 attempted to return to the facility after being discharged from medical care; however, facility staff informed the resident and/or responsible parties that the resident could not return due to the R1's behavioral condition. Interviews with Administrator Assistance confirmed that the resident was not permitted re-entry at that time.

Documentation reviewed by LPA did not indicate that the facility had completed the required eviction procedures or provided appropriate written notice in accordance with applicable regulations prior to refusing the resident’s return. Additionally, records reviewed did not support that the resident’s admission agreement had been lawfully terminated before the refusal of re-entry.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation that staff refused the resident re-entry to the facility is Substantiated.

An exit interview is conducted, and a copy of the report with appeal rights is provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20260522084539

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: A-R RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 015600467
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/01/2026 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will submit a self-certified letter in agreeing to ensure that all residents are permitted re-entry to the facility unless lawful eviction and discharge procedures have been completed in accordance with California Code of Regulations and applicable laws. Submitted to CCLD by POC date.
	8 9 10 11 12 13 14	Based on record review, the licensee did not comply with the section cited above because the facility staff refused the resident re-entry after the resident’s discharge from the hospital on 5/23/26.	8 9 10 11 12 13 14
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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: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC9099 (FAS) - (06/04)

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