019200020-9-20-2023-15-AS-BFOG-CZU5ZE-20240125192350

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200020
Report Date: 09/20/2023
Date Signed: 09/20/2023 12:43:57 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
09/12/2023 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20230912113008

FACILITY NAME:	GOOD SAMARITAN RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	019200020
ADMINISTRATOR:	FRANKLIN E. BAUTISTA		FACILITY TYPE:	735
ADDRESS:	275 JACKSON STREET		TELEPHONE:	(510) 886-1821
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY:	6	CENSUS: 6	DATE:	09/20/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Franklin Bautista, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff hit client.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kelly Nguyen arrived unannounced to conduct investigation on the above allegation. LPA met with staff Ellen Jovero; LPA explained the purpose of the visit. Administrator Franklin Bautista later arrived.

At 9:55 am, LPA interviewed Client 1 (C1). C1 was able to respond to LPA with a nod and a couple of words. Based on an interview with C1, C1 states that he doesn’t like the facility, but none of the staff here hurts anyone here. At 10:15am LPA interviewed Client 2 (C2). C2 stated that staff here tried to prevent me from AWOL, but none of the staff here hit me. At 11:00am LPA interview Client 3 (C3). C3 stated that “I don’t see any staff here hit any of my house mates”. LPA interviewed S1, S2, S3, S4, and S5 all stated that C2 is the one that attacks all the staff due to C2 behaviors. All 5 staff stated that they have never hit any clients here at the facility.

Based on interviews and records review, the above allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted and a copy of this report is provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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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