015601051-12-22-2021-15-AS-KHOS-CKBNTU-20221018104521

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601051
Report Date: 12/22/2021
Date Signed: 12/22/2021 05:06:50 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
12/13/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20211213152259

FACILITY NAME:	LA CONCEPCION RESIDENTIAL CARE HOME		FACILITY NUMBER:	015601051
ADMINISTRATOR:	CONCEPCION, CRISTINA		FACILITY TYPE:	740
ADDRESS:	4419 JACINTO DR		TELEPHONE:	(510) 574-0755
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	6	CENSUS: 4	DATE:	12/22/2021
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:			TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Neglect

INVESTIGATION FINDINGS:

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On 12/22/2021 Licensing Program Analyst (LPA) L. Ibo visited the facility to conduct initial 10 days visit . LPA explained that the reason for the visit that a complaint allegation of neglect was filed . LPA met with Administrator Cristina C.

During the complaint investigation LPA conducted documents review on the following document but not limited to, physician’s report,medical records & hospital discharge. LPA conducted interview with residents in care. LPA tried to interview R3 & R4 but they are not responding to LPAs questions. According to R1 & R2 they are happy and living comfortable at the facility, the staff try their best to help the resident, both R1 & R2 feels that they staff are not neglecting the residents.

Continuet to Lic9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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-20211213152259

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: LA CONCEPCION RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601051
	VISIT DATE: 12/22/2021

NARRATIVE

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Based on information gathered during the investigation, there was not a substantial amount of evidence to support the allegation and no independent evidence or witnesses could be obtained to support that neglect happened to resident. 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 conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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