019200020-4-16-2026-15-AS-BFOG-DTU34J-20260506175513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200020
Report Date: 04/16/2026
Date Signed: 04/16/2026 02:54:18 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
04/15/2026 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20260415112457

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:	04/16/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Frankline Baustita, Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not ensure resident was safe from harm
Staff did not ensure resident was safe from other residents

INVESTIGATION FINDINGS:

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On 04/16/2026 at 9:30 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct the 10 Day Initial Complaint Investigation and deliver findings for the above allegations. LPA met with caregiver Ellen Joven and explained the nature of the visit. Administrator (ADM) Franklin Bautista was not present for the entire time and stated that Ellen has the authority to sign the report.

During the visit, LPA collected the following documents: R1's LIC602, R1's Medication List, R1's Appraisal Needs and Services Plan, R1's preventative care plan from the Center for Applied Behavior Analysis (CABA) Agency Client Roster, and Staff Roster.

Continued from LIC9099c....

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

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-20260415112457

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: 04/16/2026

NARRATIVE

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Report Continued...

Allegation: Staff did not ensure resident was safe from harm- Unsubstantiated

It was alleged that staff did not ensure the clients were safe from harm. During the course of the investigation, in addition to collecting documents, LPA spoke with ADM, four (4) staff members, and three (3) residents. Residents 1 (R1), Resident 2 (R2), and Resident 3 (R3) all spoke highly of the staff and the care provided. R1 reports feeling safe in the home around staff and other housemates. Based on the client’s interview, W1 did not reveal any concerns regarding their safety, and the resident reported feeling safe in the facility. Staff interviews indicated that procedures are in place to monitor and protect residents, and no staff reported any incidents or observations suggesting that a residents was at risk of harm. The Administrator confirmed that documentation, or evidence of unsafe conditions or incidents involving the residents, is an ongoing discussion with R1 care team, including but not limited to R1 RCEB CM, R1 RCEB CM Supervisor, RCEB Behaviorist (psychologist), and the Center for Applied Behavior Analysis (CABA) Agency.

Report continued on LIC 9099c1...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20260415112457

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: 04/16/2026

NARRATIVE

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Report continued LIC 9099c1...

Allegation: Staff did not ensure the residents were safe from other residents - Unsubstantiated

It was alleged that staff did not ensure the residents were safe from other residents. Based on interviews with four staff members, three residents, and the Administrator, as well as a review of records, the allegation is that staff did not ensure the residents was safe from other residents. Staff reported actively monitoring residents interactions and intervening when necessary to prevent conflicts or unsafe situations between residents. The Administrator stated that the facility has policies and procedures in place to address residents-to-residents interactions and ensure a safe environment.
Residents interviewed did not report concerns regarding their safety from other residents, nor did they describe any incidents in which they felt threatened or harmed by another residents.

Although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations occurred; the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report is provided to Care Staff Ellen.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

LIC9099 (FAS) - (06/04)

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