019200020-7-3-2024-15-AS-KHOS-D9FJVW-20240925072349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200020
Report Date: 07/03/2024
Date Signed: 07/03/2024 11:30:21 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
06/25/2024 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20240625091924

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:	07/03/2024
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Franklien E, Bautista, Administrator		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Client was inappropriately touched by staff

INVESTIGATION FINDINGS:

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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 10:25 am, LPA interviewed S1, S2, C1, and CM Regional of the East Bay (RCEB). C1 was able to respond to LPA questions. When asked C1 deny that C1 was being touch inappropriately by facility staff. Based on an interview with C1, C1 states that “NO…no staff touch me inappropriately. No staff abuse me...but sometime I don’t want to stay here. I don’t like it here. I want to go with my mom". LPA interviewed S1, S2 and CM all stated that C1 tend to make false statement about the facility staff.

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.
A exit interview conducted, and a copy of this report provided via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

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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