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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200139
Report Date: 08/22/2022
Date Signed: 08/22/2022 08:19:45 PM

Substantiated


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
08/17/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220817123402
FACILITY NAME:NEW BELLEVUE MANORFACILITY NUMBER:
019200139
ADMINISTRATOR:SHIELHA MUNIZFACILITY TYPE:
735
ADDRESS:3056 RANDALL WAYTELEPHONE:
(510) 538-3053
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:12CENSUS: 7DATE:
08/22/2022
UNANNOUNCEDTIME BEGAN:
04:25 PM
MET WITH:Juliana Taburaza/Licensee and
Sheilha Muniz/Administrator Staff hit resident in care. 		TIME COMPLETED:
08:30 PM
ALLEGATION(S):
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Staff not providing adequate care and supervision resulting in resident leaving the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with staff, Aileen Fajardo and Emmanuel Pajardo. LPA called and spoke with Juliana Taburaza, licensee, who arrived after several minutes with Sheilha Muniz, administrator. LPA informed the purpose of visit.

LPA reviewed residents' file and obtained copies of residents' (R1, R2, and R3) documents. Review of R1's Pre-placement Appraisal revealed R1 has wandering behavior. LIC602 Physician's Report showed R1 can not leave the facility unassisted. Facility submitted Special Incident Reports indicating R1 AWOLed twice this month of August which LPA confirmed with Shielha Muniz and Juliana Taburaza,


...,..continued next page (9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
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 4
Control Number 15-AS-20220817123402
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: NEW BELLEVUE MANOR
FACILITY NUMBER: 019200139
VISIT DATE: 08/22/2022
NARRATIVE
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Based on information obtained, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Juliana Taburaza and Sheila Muniz.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20220817123402
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: NEW BELLEVUE MANOR
FACILITY NUMBER: 019200139
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2022
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.

-This requirement is not met as evidenced by:
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Licensee to in-service the staff and submit copy of training topic with attendees.signatures by 8/23/2022.
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-Based on records review and interview, the licensee did not comply with the section above. R1 was able to AWOL which posed immediate safety risks to person in care,
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4