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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200020
Report Date: 08/05/2024
Date Signed: 08/05/2024 03:43:11 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-20240730153323
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:
08/05/2024
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Frankline Bautista, Administrator TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff sexually assaulted client while in care.
Staff yelled 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 sexually assaulted client while in care: Unsubstantiated

During the course of investigation LPA interviewed 5 staff and 5 clients. It was alleged that Staff sexually assaulted client while in care, however after LPA interviewed with C1, C1 stated “that it didn’t happen, and none of the staff here touch or assaulted me”. 5 out of 5 Clients all stated that none of the staff sexually assaulted them, nor they have seen any staff sexually assaulted any client. 5 out of 5 staff stated, “they did not nor see any of the staff sexually assaulted any clients”.

Report continues 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)
Page: 1 of 2
Control Number 15-AS-20240730153323
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 yelled and threaten client while in care: Unsubstantiated

This allegation is the same as the allegation in complaint number (15-AS-20240730154632). LPA investigated this allegation and found it to be unsubstantiated.

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)
Page: 2 of 2