015601284-12-3-2021-15-AS-KHOS-C9VKBA-20211220064512

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601284
Report Date: 12/03/2021
Date Signed: 12/03/2021 03:00:47 PM

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
12/01/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20211201162014

FACILITY NAME:	RAKSHA 6		FACILITY NUMBER:	015601284
ADMINISTRATOR:	BHUTANI, NALANI		FACILITY TYPE:	740
ADDRESS:	1133 GARFIELD AVENUE		TELEPHONE:	(510) 558-7241
CITY:	ALBANY	STATE: CA	ZIP CODE:	94706
CAPACITY:	6	CENSUS: 4	DATE:	12/03/2021
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Nalini Bhutani/Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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9

Personal rights.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a 10-day complaint visit. LPA met with Carmen Portillo-Diaz, care staff. LPA requested to call Nalini Bhutani, administrator. Nalini arrived after about 10 minutes. LPA informed the purpose of visit.

LPA obtained copy of LIC9020 Register of Facility Residents which showed resident (R1) not on the list. LPA verified, and Carmen Portillo-Diaz and Nalini Bhutani stated R1 does not live in this facility. Therefore, the complaint is close as unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted and copy of this report provided to Nalini Bhutani.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

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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