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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200020
Report Date: 07/03/2024
Date Signed: 07/03/2024 12:28:10 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
06/28/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20240628154430
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:
07/03/2024
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Frankline Bautista, Administrator TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff mentally abusing client.
Faciility staff neglecting client.
Facility staff verbally abuses client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Nguyen arrived unannounced to conduct investigation on the above allegation. LPA explained the purpose of the visit to administrator (AD) Franklin Bautista.
During the course of investigation LPA interviewed administrator (AD), CM Reginal of the East Bay (RCEB) and C1.

Allegation: Facility staff mentally abusing client: Unsubstantiated
It was alleged that facility staff mentally abusing client, however after LPA interviewed with C1, C1 stated “No! they do not do that. They don’t blame me for anything or abuse me”. Administrator stated that staff including myself do not use any shaming, or used any words that would make C1 feel down. C1 CM stated that C1 makes statement that are not true.

Report contine on LIC 9099c...
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)
Page: 1 of 2
Control Number 15-AS-20240628154430
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: 07/03/2024
NARRATIVE
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Allegation: Facility staff neglecting Client: Unsubstantiated

It was alleged that facility staff mentally abusing client, however after LPA interviewed with C1, C1 stated “No, S1 is with me all the time. I go with S2 to the library, and they give me what I want and needs. I don’t like to stay here. I want to stay at another place. According to CM and AD, C1 is working with Crises Response Project (CRP), and California Start, and is in the process of enrolling C1 to Catalyst Care adult day program.

Allegation: Facility staff verbally abuses client: Unsubstantiated

It was alleged that facility staff mentally abusing client, however after LPA interviewed with C1, C1 stated “NO…S1 and AD are really nice to me. I just want to go with my mom. They don’t say anything mean to me”.

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.



An exit interview is conducted, and this report provided via email.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2