019200020-12-29-2025-15-AS-BFOG-DQR36C-20260127165808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200020
Report Date: 12/29/2025
Date Signed: 12/29/2025 09:49:02 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
11/20/2025 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20251120100911

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:	12/29/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Ellen Jovero, Caregiver		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff hit resident
Staff touched resident inapropriatly
Staff do not treat resident with respect

INVESTIGATION FINDINGS:

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On 12/29/25 at 8 am, Licensing Program Analysts (LPAs) K. Nguyen and A. Christy arrived unannounced to delivered finding on the above allegations. LPAs explained the purpose of the visit to Administrator (ADM), Franklin Bautista via telephone. AMD was not available to come to the facility and gave verbal permission to caregiver Ellen Jovero to sign the report.

Allegation: Staff hit resident: Unsubstantiated

The Department investigated the allegation that staff hit the resident. The investigation included interviews with Resident 1 (R1), as well as a review of available records and documentation. On 11/06/2025 the department interviewed, R1 did not provide consistent or detailed information supporting the allegation. R1 talked about R1 past experienced of an ex-companion that touched/ hit R1. However, R1 denial that facility staff hit R1. Therefore, the allegation is unsubstantiated.

Report continues on LIC 9099c...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025

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-20251120100911

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: 12/29/2025

NARRATIVE

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Allegation: Staff touched residents inappropriately: Unsubstantiated

During the course of investigation, it was alleged that staff touched residents inappropriately. The investigation included interviews with residents, and staff, as well as a review of available records and documentation. During interviews, the resident 1 (R1) did not provide consistent or specific details to support the allegation, and no witnesses corroborated that inappropriate touching occurred. On 12/29/25 LPA interviewed Resident 1 (R1) denied the allegation and stated that the staff did not touch R1 inappropriately. Based on the information obtained, there is insufficient evidence to determine that staff touched residents inappropriately as alleged. Therefore, the allegation is unsubstantiated.

Allegation: Staff do not treat the residents with respect: Unsubstantiated

During the course of investigation, it was alleged that staff did not treat the residents with respect. The investigation included interviews with the residents and staff, as well as a review of relevant records and documentation. On 12/29/25 LPA interviewed Resident 1 (R1), Resident 2 (R2), and Resident 3 (R3). R1, R2, and R3 stated that all staff here are nice and treat them with respect. When asked, R1 denied the allegation, and the information obtained did not indicate a pattern of disrespectful behavior. Based on the evidence reviewed, there is insufficient information to support the allegation. Therefore, the allegation is unsubstantiated.

Although the allegations 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.

An exit interview is conducted, and this report is provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025

LIC9099 (FAS) - (06/04)

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