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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200020
Report Date: 08/30/2023
Date Signed: 08/30/2023 05:31:50 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
05/19/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230519135949
FACILITY NAME:GOOD SAMARITAN RESIDENTIAL CARE FACILITYFACILITY NUMBER:
019200020
ADMINISTRATOR:FRANKLIN E. BAUTISTAFACILITY TYPE:
735
ADDRESS:275 JACKSON STREETTELEPHONE:
(510) 886-1821
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:6CENSUS: 6DATE:
08/30/2023
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Frank Bautista, AdministratorTIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Staff forced client to eat non-food items off the floor and sofa.
Staff intimidates client.
Staff is not allowing client to use the phone.
INVESTIGATION FINDINGS:
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On 8/30/2023 at 4:45PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with staff, Arturo Ticman and explained the purpose of the visit. Administrator, Frank Bautista arrived 20 minutes later.

During the course of investigation, LPA interviewed 5 clients, 2 staff, and complainant. LPA also obtained and reviewed documents including: IPP (individual program plan).

Staff forced client to eat non-food items off the floor and sofa.
Interview with clients and staff revealed there was no one who witnessed staff forced client to eat non-food items.
(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
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-20230519135949
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: GOOD SAMARITAN RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200020
VISIT DATE: 08/30/2023
NARRATIVE
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Staff intimidates client.
Interview with clients and staff indicated there was no one who witnessed staff intimidating clients. Client stated they have not witnessed staff be rude to clients.

Staff is not allowing client to use the phone.
Interview with clients and staff revealed that clients are able to use the facility phone. LPA observed facility has 2 cordless phones that clients can borrow.

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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2