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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200139
Report Date: 02/10/2023
Date Signed: 02/10/2023 05:29:52 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
12/23/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211223081419
FACILITY NAME:NEW BELLEVUE MANORFACILITY NUMBER:
019200139
ADMINISTRATOR:FEDERICO ROMEROFACILITY TYPE:
735
ADDRESS:3056 RANDALL WAYTELEPHONE:
(510) 538-3053
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:12CENSUS: 7DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Juliana Taburaza, AdministratorTIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Facility failed to notify conservator of incident
INVESTIGATION FINDINGS:
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On 2/10/2023 starting at 3:00 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA was greeted by Care Staff, Emmanuel Fajardo and LPA explained the purpose of the visit. Administrator, Juliana Taburaza later arrived at 4:15 PM

During the course of the investigation, LPA obtained information, reviewed records, collected documents, interviewed staff and clients. It was alleged facility failed to notify concervator of incident. Based on record review of incident report completed on 12/23/2021, it indicates C3's case manager was informed of the incident that occurred between C1 and C3 on 11/23/2021. S1 was advised by C3's case manager that it was not necessary to inform C1's responsible party because there were no bruises observed by staff. Therefore, C1's responsible party was not notified.

REPORT CONTINUES ON 9099C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
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 5
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
12/23/2021 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20211223081419

FACILITY NAME:NEW BELLEVUE MANORFACILITY NUMBER:
019200139
ADMINISTRATOR:FEDERICO ROMEROFACILITY TYPE:
735
ADDRESS:3056 RANDALL WAYTELEPHONE:
(510) 538-3053
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:12CENSUS: 7DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Juliana Taburaza, AdministratorTIME COMPLETED:
05:40 PM
ALLEGATION(S):
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9
Staff is not assisting with resident's medical needs.
Resident hit another resident in care
INVESTIGATION FINDINGS:
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On 2/10/2023 starting at 3:00 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegations. Upon arrival, LPA was greeted by Care Staff, Emmanuel Fajardo and LPA explained the purpose of the visit. Administrator

During the course of the investigation, LPA obtained information, reviewed records, collected documents, interviewed staff and clients. It was alleged staff is not assisting with resident's medical needs. Based on record review, facility was in communication with C1's doctor regarding C1's c-pap machine. LPA discovered during an interview with S1 and S2 that once C1 received a replacement part for c-pap's machine, S2 assisted C1.

REPORT CONTINUES ON 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20211223081419
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: 02/10/2023
NARRATIVE
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It was alleged resident hit another resident in care. However, based on interview with S4, C1 and C3 had a misunderstanding and C3 threw a plastic object at C1. S4 stated both clients were separated and redirected. S4 conducted a body check and did not observe any bruising on C1.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided to Administrator.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20211223081419
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: 02/10/2023
NARRATIVE
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Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided to Administrator.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20211223081419
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: 02/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/24/2023
Section Cited
CCR
80061(f)
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80061(f) REPORTING REQUIREMENTS
(f) The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any.

This requirement is not met as evidenced by:
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By POC date, Administrator will review regulation and train staff and submit a copy of training agenda with staff signature to CCLD.
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Based on record review and interview, Licensee did not comply with the section cited above by not reporting the incident on 11/23/2021 to C1's responsible party which poses a potential health and safety risk to persons 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5