019200020-8-5-2024-15-AS-KHOS-D9FKEA-20240925075002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200020
Report Date: 08/05/2024
Date Signed: 08/05/2024 03:41:02 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
07/30/2024 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20240730154632

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:	08/05/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Frankline Bautista, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff intimidated client while in care.
Staff does not provide a safe environment for the clients in care.
Staff does not provide hygiene care to client.
Staff yell and threaten client while in care.

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. AD had to leave the facility and verbal gave permission for staff Ellen to sign the report.

Allegation: Staff intimidated client while in care.: Unsubstantiated

During the course of investigation LPA interviewed 5 staff and 5 clients. It was alleged that Staff intimidated client while in care, however after LPA interviewed with C1, C1 stated “No! staff doesn’t intimidate me”. 5 out of 5 staff stated they don’t intimidate any clients in the facility. LPA reviewed C1 behavior assessment and Plan (Functional Assessment) indicated C1 lies and makes false accusation about other. C1 believes others are lying about him, due to C1 Paranoia. 5 out of 5 clients stated that staff does not intimidate them.

Report continue on LIC 9099c...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

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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Control Number 15-AS-20240730154632

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: 08/05/2024

NARRATIVE

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Allegation: Staff does not provide a safe environment for the clients in care: Unsubstantiated

During the course of investigation LPA interviewed 5 staff and 5 clients. It was alleged that Staff does not provide a safe environment for the clients in care, however after LPA interviewed with C1, C1 stated that C1 want to be transfer because C1 doesn’t like one of the clients at the facility. 5 out of 5 staff stated that they tried their best to make sure all the clients here feel safe and comfortable. LPA asked C1 do C1 feel safe at the facility, C1 said sometimes I hear voices in my head. 5 out of 5 clients stated they all feel safe at the facility.

Allegation: Staff does not provide hygiene care to client: Unsubstantiated

During the course of investigation LPA interviewed 5 staff and 5 clients. 5 out of 5 clients stated that the staff provide hygiene care for all of us. 5 out of 5 clients stated that all the staff assisted them with hygiene care. S2 stated that S2 is the one that provided hygiene care for C1, but sometime C1 doesn’t want to change out of C1 clothes when C1 make an accident on C1 self.

Allegation: Staff yell and threaten client while in care: Unsubstantiated

During the course of investigation LPA interviewed 5 staff and 5 clients. 5 out of 5 clients stated that the staff did not yell at them, and all the staff here is very nice. C1 stated that C1 hear voices that are yelling at C1. C1 stated that C1 doesn’t remembered when asked about whom yelled at C1.

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.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

LIC9099 (FAS) - (06/04)

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