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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600526
Report Date: 12/18/2025
Date Signed: 12/18/2025 01:12:27 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
12/10/2025 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20251210111026
FACILITY NAME:ELDERS INN ON WEBSTERFACILITY NUMBER:
015600526
ADMINISTRATOR:MARIE ANN LAGASCAFACILITY TYPE:
740
ADDRESS:1721 WEBSTER STREETTELEPHONE:
(510) 521-9200
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:60CENSUS: 42DATE:
12/18/2025
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Rolinda Noquillo, AdministratorTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff are blocking the required posted notifications from the residents
INVESTIGATION FINDINGS:
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On 12/18/2025 at 12:20pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a 10-day initial complaint visit and deliver complaint findings for the allegation above. LPA met with Rolinda Noquillo, Administrator, and explained the reason for the visit.

Allegation: Staff are blocking the required posted notifications from the residents

During the course of the investigation LPA interviewed S1, reviewed picture that was submitted with complaint, and observed area where the required posted notification is posted. The picture submitted showed a plant obstructing the Ombudsman and RCFE complaint poster. LPA observed during today's visit that the notifications were no longer obstructed.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
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 3
Control Number 15-AS-20251210111026
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: ELDERS INN ON WEBSTER
FACILITY NUMBER: 015600526
VISIT DATE: 12/18/2025
NARRATIVE
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Continued from LIC9099C.

Based on LPA’s interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC9099D.

Exit interview conducted. A copy of the appeal rights and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20251210111026
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: ELDERS INN ON WEBSTER
FACILITY NUMBER: 015600526
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/25/2025
Section Cited
CCR
87468(c)
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(c) Licensees shall... post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public.
This requirement was not met as evidence by:
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Administrator removed plant from obstructing required notifications prior to visit. Deficiency cleared.
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Based on interview and record review the Licensee did not comply with the section cited above in having the required notifications unblocked, which poses a potential personal rights risk to persons 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3