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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601449
Report Date: 05/02/2022
Date Signed: 05/02/2022 08:59:14 AM

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
09/03/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200903093736
FACILITY NAME:OLD OAK GOLDEN VILLA, LLCFACILITY NUMBER:
015601449
ADMINISTRATOR:NUNEZ, CORAZON & MAXIMINOFACILITY TYPE:
740
ADDRESS:970 OLD OAK ROADTELEPHONE:
(925) 245-1818
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 6DATE:
05/02/2022
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Marietta Bugayong, CaregiverTIME COMPLETED:
09:10 AM
ALLEGATION(S):
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Staff did not seek medical care for resident.
Staff financially abused resident.
INVESTIGATION FINDINGS:
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On 5/2/2022 at 8:35AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver complaint findings for the allegations above. LPA met with caregiver, Marietta Bugayong.

During the investigation, LPA interviewed 2 staff, witnesses, and complainant. LPA obtained and reviewed R1’s file including physician’s report, care plan, care notes, doctor’s referral and reports, discharge paper, incident report, and police report.

Based on documents review, staff have been taking R1 to the doctor and specialist for R1’s diagnosis. However, R1 have refused to see the doctors which was report to CCLD RO (Community Care Licensing Division Regional Office) and noted in the facility care note.

(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
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 2
Control Number 15-AS-20200903093736
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: OLD OAK GOLDEN VILLA, LLC
FACILITY NUMBER: 015601449
VISIT DATE: 05/02/2022
NARRATIVE
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Interview with staff indicated that R1 was taken to the doctors. Doctor’s referral and discharge documents indicated that staff have seek medical care for R1.

Based on the Department's Audit Report, there was no evidence shown staff financially abused R1.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2