015601483-9-21-2021-15-AS-KHOS-CKAM7E-20221017092125

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601483
Report Date: 09/21/2021
Date Signed: 09/21/2021 03:30:34 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
09/16/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20210916152821

FACILITY NAME:	ST. LOURDES HOME		FACILITY NUMBER:	015601483
ADMINISTRATOR:	BALINTONA, JUSTINO		FACILITY TYPE:	740
ADDRESS:	1626 ASHBURY LANE		TELEPHONE:	(510) 265-0818
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	6	CENSUS: 6	DATE:	09/21/2021
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:			TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff is not allowing resident’s visitor into the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Justino Balintona, licensee-administrator, and informed the purpose of LPA's visit.

It was alleged that the staff is not allowing resident's visitor, V1 (a staff from advocacy agency), into the facility.

LPA interviewed Balintona, staff (S1), V1 and resident R1. Balintona and staff S1 stated they did not allow V1 when V1 came in the first time due to the identification presented to them by V1 does not bear the name of the advocacy agency they know. Balintona also indicated that the number on the business card he obtained from V1 has a different telephone number of the advocay agency he knows. LPA verified and confirmed with V1 who stated his business card does not have in it the main office number of their agency.

..........continued next page

Unsubstantiated

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: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

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-20210916152821

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. LOURDES HOME	FACILITY NUMBER: 015601483
	VISIT DATE: 09/21/2021

NARRATIVE

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Balintona indicated that for the safety of the residents and because V1's card does not bear the general number of the agency V1 represents, he went to Adult and Senior Care Oakland Regional Office (ASC RO) on the same day V1 came to the facility the first time to confirm the legitimacy of advocacy agency indicated on V1's business card. This is consistent with the information provided/obtained by LPA. Balintona and S1 both stated V1 was allowed entry when V1 came back to the facility which was confirmed by LPA with R1.

Based on facility's intent to protect the safety of residents and after the administrator took all the necessary actions to verify the validity of advocacy agency allowed V1 entry to the facility, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided to Justino Balintona.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC9099 (FAS) - (06/04)

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