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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600552
Report Date: 10/09/2025
Date Signed: 10/17/2025 02:37:25 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
08/13/2025 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250813120247
FACILITY NAME:ST. MARY'S HOMEFACILITY NUMBER:
015600552
ADMINISTRATOR:BOLLOSO, JOVITAFACILITY TYPE:
735
ADDRESS:34921 PERRY ROADTELEPHONE:
(510) 429-1584
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 5DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Consuelo BanagaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff make client assist other clients at the facility and other facility owned by Licensee
Staff make client carry heavy items such as water, rice and laundry detergent
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analysts (LPAs) Luisa Fontanilla and Patricia Manalo arrived unannounced at around 10:30 to deliver findings for the above allegations.

LPAs met with Consuelo Banaga and explained the purpose of the visit.
On 8/14/2025, LPA conducted 10-day visit, obtained records and interviewed 4 of 6 clients and staff. LPA also interviewed Client 2 (C2) Case Manager.

Based on interviews conducted with 4 of 6 clients, C4 who is non ambulatory and uses a walker frequently falls. C1 and C2 are asked to help lift up C4 from the floor because staff are unable to. Staff interviewed confirmed with LPA that C1 and C2 are asked to help with lifting everytime C4 falls. And 2 of 6 clients confirmed with LPA grocery shopping with the Administrator and loading commodities such as rice, water, laundry detergent, and other supplies into the vehicle. The goods then get delivered to the two homes with staff unloading.
The Administrator confirmed with LPA about C1 and C2 helping with groceries voluntarily. She states that the clients have expressed desire to help with grocery shopping.
Based on interviews conducted, the above allegations are substantiated.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D.

Exit interview was conducted, Appeal Rights and copy of this report were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
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-20250813120247
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: ST. MARY'S HOME
FACILITY NUMBER: 015600552
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2025
Section Cited
CCR
80072(a)(1)
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80072(a)(1) Personal Rights
a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
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The Administrator will submit self-certification indicating that no client will be asked to assist with:
1) lifting/escorting dr. appt other clients 2) lifting heavy items when shopping and submit to CCL by POC date.
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(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by: Based on interviews conducted, licensee did not comply with the section cited above by 1) having C1 lift heavy items during grocery shopping and 2) having C1 and C2 lift up C4 and another client at the Begonia RCFE owned by the same Licensee each time they fall which poses an immediate risk to the health and safety of 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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3