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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200043
Report Date: 02/25/2022
Date Signed: 02/25/2022 11:44:44 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
05/20/2021 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20210520143002
FACILITY NAME:ARLEEN'S RESIDENTIAL CARE, INC.FACILITY NUMBER:
019200043
ADMINISTRATOR:MARCELO, TYLERJAMESFACILITY TYPE:
735
ADDRESS:27749 PENSACOLA WAYTELEPHONE:
(510) 670-2822
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:6CENSUS: DATE:
02/25/2022
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Lilibeth Lopez, AdministratorTIME COMPLETED:
11:55 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day2/25/22, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings on the above allegation and met with Lilibeth Lopez.

On May 24, 2021, LPA Luisa Fontanilla initiated 10-day investigation, interviewed 4 staff and Client 1 (C1) via video call. On 5/25/2021, LPA reviewed C1’s Individual Program Plan (IPP).
All 4 staff interviewed denied hitting or hurting C1 or any other client.
When interviewed by LPA, C1 states staff are nice and feels safe living at the facility. During the tele visit, LPA observed C1 laughing and dancing with one of the staff.
Administrator states C1 has been doing well since moving to this facility.
Based on interviews conducted and LPA observation, the above allegation is unsubstantiated.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview was conducted with Administrator and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
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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