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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601507
Report Date: 04/15/2022
Date Signed: 04/15/2022 12:55:51 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
04/05/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220405130512
FACILITY NAME:OAKCREEKFACILITY NUMBER:
015601507
ADMINISTRATOR:ELIZABETH CARSONFACILITY TYPE:
740
ADDRESS:6127 E. CASTRO VALLEY BLVD.TELEPHONE:
(510) 889-7515
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94552
CAPACITY:38CENSUS: 19DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Elizabeth Carson, AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Uncleared staff working at facility.
INVESTIGATION FINDINGS:
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On 4/15/22 at 8:45am Licensing Program Analysts (LPAs), Catherine Lin and Kelly Nguyen conducted an unannounced complaint investigation regarding the above allegation and deliver investigation findings. LPA met with Administrator Elizabeth Carson and explained the purpose of the visit.

The Department has investigated this allegation and per interviews and records review found that S3 does not have proper fingerprint clearance to be at the facility. It has been found that S3 has been at the facility working as the Activities Director since 9/20/2021, S1 and S2 admitted that S3 has been interacting variety activities with residents in care at the facility.

Based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Continue on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
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 3
Control Number 15-AS-20220405130512
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: OAKCREEK
FACILITY NUMBER: 015601507
VISIT DATE: 04/15/2022
NARRATIVE
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Per California Code of Regulations (Title 22, Division 6, Chapter 8), the deficiency is being cited on the attached LIC 9099D. Facility will also be accessed with a Civil Penalty for having a non-cleared staff at the facility.

Exit interview conducted with Administrator, copies of the reports and appeal right provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220405130512
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: OAKCREEK
FACILITY NUMBER: 015601507
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2022
Section Cited
CCR
87355(e)(1)
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87355 - Criminal Record Clearance
(e)(1) Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. This requirement is not met as evidenced by:
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Administrator agreed to remove S3 from the facility until fingerprint clearance is obtained, In addition, Administrator will provide in writing a plan to ensure anyone who is hired or residing at the facility must have criminal record clearance prior to hiring, to CCL by the POC due date.

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Based on observation, interview, and records review the licensee did not comply with the section cited above. It was found that S3 was present at the facility without having proper fingerprint clearance, which poses an immediate safety risk of residents in care.
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$500.00 Civil Penalty was assessed and issued.
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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: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3