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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200020
Report Date: 12/29/2025
Date Signed: 12/29/2025 10:54:11 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
12/19/2025 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20251219140311
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:
12/29/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ellen Jovero, Caregiver TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Client sustained unexplained bruises while in care
INVESTIGATION FINDINGS:
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On 12/29/2025 at 10:00AM, Licesning Program Analysts (LPAs) K. Nguyen and A. Christy arrived unannounced to conduct the 10 Day Initial Complaint Investigation and deliver findings for the above allegation. LPAs met with caregiver Ellen Joven and explained the nature of the visit. Administrator Franklin Bautista could not be in person and stated Ellen has authority to sign any forms.

During visit, LPAs collected the following documents: R1's LIC602, R1's Medication List, R1's Appraisal Needs and Services Plan, Client Roster, and Staff Roster.

Continued on LIC9099C.....
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)
Page: 1 of 2
Control Number 15-AS-20251219140311
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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Continued from LIC9099.....

Allegation: Client sustained unexplained bruises while in care

During the course of investigation, in addition to collecting documents, LPAs spoke with two (2) staff members and three (3) residents. Residents R1, R2, and R3 all spoke highly of the staff and care provided. R1 notes that they feel safe in the home and around the staff. All three residents stated they have not seen staff treat anyone unfairly and that they have not noticed any forms of abuse to residents.

Staff members S1 and S2 stated they never noticed any bruising on R1 until R1 returned from the hospital. S1 notes that sometimes restraints are used to secured R1 on the gurney restraining belt during transportation to the hospital. S2 confirms that restraints were used during transportation of R1 during last hospital visit, and were used on the arms where bruising formed by the gurney restraining belt.

LPAs have fully conducted an investigation for the above allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report was made available to staff.
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)
Page: 2 of 2