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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200148
Report Date: 12/17/2024
Date Signed: 12/17/2024 06:42:09 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
06/19/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230619153702
FACILITY NAME:REMINGTON CARE HOME #2FACILITY NUMBER:
019200148
ADMINISTRATOR:BETH NUNEZFACILITY TYPE:
735
ADDRESS:27481 ORLANDO AVETELEPHONE:
(510) 785-9215
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: 5DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Jesusa 'Suzette' Timbol/StaffTIME COMPLETED:
06:50 PM
ALLEGATION(S):
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Facility staff making degrading comments about a resident on social media.
INVESTIGATION FINDINGS:
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On this day, 12/17/24, at 5:15 pm, Licensing Program Analyst Delmundo (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA was granted entry by Jesusa 'Suzette' Timbol, staff. LPA also met with another staff, Mickey Anne Fabian. LPA called and spoke on the phone with Beth Nunez, administrator (ADM), and informed the reason for visit. ADM authorized Jesusa Timbol to sign and receive this report.

LPA obtained copies of LIC9020 Register of Facility Clients/Residents and staff schedule, and conducted interviews.

Reporting party stated that staff, S2, posted on social media and that S2 responded to a friend and made degrading comments and laughed at resident, RF, by calling RF ‘abnormal’.

...........continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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 7
Control Number 15-AS-20230619153702
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: REMINGTON CARE HOME #2
FACILITY NUMBER: 019200148
VISIT DATE: 12/17/2024
NARRATIVE
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 LPA interviewed S2 who admitted and stated it was her mistake posting in the social media.

Based on interview, the preponderance of evidence is met, therefore, the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. 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 ADM.

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: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20230619153702
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: REMINGTON CARE HOME #2
FACILITY NUMBER: 019200148
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2024
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Staff deleted the posting.

Administrator to in-service the staff and submit copy of training topic with attendees signatures by 12/31/24.
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-This requirement is not met as evidenced by:

-Based on interview, the licensee did not comply with the section above when staff posted a degrading comment in social media which posed a potential personal rights risk 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: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
06/19/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230619153702

FACILITY NAME:REMINGTON CARE HOME #2FACILITY NUMBER:
019200148
ADMINISTRATOR:BETH NUNEZFACILITY TYPE:
735
ADDRESS:27481 ORLANDO AVETELEPHONE:
(510) 785-9215
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: 5DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Jesusa 'Suzette' Timbol/StaffTIME COMPLETED:
06:50 PM
ALLEGATION(S):
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-Resident sustained an unexplained injury while in care.
-Staff hit resident.
-Facility is operating out of ratio.
-Facility is falsifying staff schedule.
-Staff failed to treat resident with dignity and respect.
-Facility failed to maintain a comfortable room temperature.
INVESTIGATION FINDINGS:
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On this day, 12/17/24, at 5:15 pm, Licensing Program Analyst Delmundo (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA was granted entry by Jesusa 'Suzette' Timbol, staff. LPA also met with the other staff, Mickey Anne Fabian. LPA called and spoke on the phone with Beth Nunez, administrator (ADM), and informed the reason for visit. ADM authorized Jesusa Timbol to sign and receive this report.

During the course of investigation, LPA obtained copies of LIC9020 Register of Facility Clients/Residents and staff schedule, and reviewed clients and staff records. LPA also obtained copies of the following residents' records: LIC601 Identification and Emergency Contact Information; LIC602 Physician's Report; Appraisal. LPA conducted inspection and observations on 6/27/23 and 3/09/24. LPA conducted staff and residents interviews on 6/20/23, 6/27/23, 3/01/24, 3/09/24, 11/01/24, 11/04/24 and 12/11/24.

.....continued on 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20230619153702
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: REMINGTON CARE HOME #2
FACILITY NUMBER: 019200148
VISIT DATE: 12/17/2024
NARRATIVE
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Page 2

LPA also reached out to Regional Center of East Bay Quality Assurance Specialist (QS) and verified the staffing indicated on the staff schedule obtained by LPA from the facility and staff schedule provided by the administrator to QS.

Allegation: Resident (R3) sustained an unexplained injury while in care.
Allegation: Staff hit resident.

Nine (9) staff (S1, S2, S3, S5, S6, S7, S8, S10, SH) were interviewed. S3 stated he and S4 reported the bruise on R3’s leg to the licensee and that they suspect S1 kicked R3. S3 also stated hearing S1 beating R1, but did not personally observed the beating. S3 also stated he witnessed S3 pushed the chair where R1 was sitting against the dining table on the day of incident between R1 and R2 in 1/21/23. S1 denied the allegation. The other 6 staff denied hitting any resident and stated not observing S1 hit residents. One of these 6 staff (S2) stated observing the bruise on R3’s leg due to medical problem and that R3 has self injurious behavior (SIB). The other staff (S10) also stated R3 has SIB which LPA confirmed upon review of R3’s record. Due to medical diagnosis, LPA was not able to obtain information from R1, R2 and R3. The other 3 residents stated not observing any staff hit other residents.

Based on interviews and records review and due to LPA not able to obtain information from 3 residents, the above 2 allegations are unsubstantiated.

Allegation: Facility is operating out of ratio.
Allegation: Facility is falsifying staff schedule.
It was alleged that licensee not adhering to staffing ratio requirement. It was further alleged that the licensee fabricated the Weekly Time Schedule of direct care staffing to utilize the 366 Staffing Hours and listed a staff on the schedule was not working in the facility. SH and S6 were also listed on the schedule 5 days/week when these 2 staff only come to the facility 2 days/week. It was further alleged that S1 was by himself working when the incident on 1/21/23 happened.


........continued on 9099C (page 3)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20230619153702
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: REMINGTON CARE HOME #2
FACILITY NUMBER: 019200148
VISIT DATE: 12/17/2024
NARRATIVE
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Page 3

Nine (9) staff (S1, S2, S3, S5, S6, S7, S8, S10, SH) were interviewed. On 6/19/23, S3 stated there were many days that only 1 staff was on duty for 6 clients especially on Saturdays and Sundays. S3 also stated on 6/20/23 that S1 was by himself working when an incident between residents, R1 and R2, happened. S1 and S5 stated they were by themselves working at a time for several months; however, these 2 staff stated that S6 and the ADM also come to the facility on the days they were by themselves working. S6 stated he was at the facility when the incident between R1 and R2 happened. The other 6 staff stated there’s always 2 staff working at a time. SH stated he was the administrator before then stepped down and Beth Nunez (ADM) took over the position. SH denied falsifying staffing records and stated there’s always at least 2 staff working at a time. SH added that during COVID there were times when they experienced short staffing, but there were no days only 1 staff working. ADM and himself work long hours to cover. LPA showed the Staffing Schedule for 2023 to S3 who works on weekends. S3 stated the schedule is correct but S3 was out when the incident between R1 and R2 happened.

LPA interviewed three residents of which 2 stated there’s always at least 2 staff working at a time. The other resident stated he was not at the facility when the incident between R1 and R2 happened. Due to the medical diagnosis of the other 3 residents, LPA was not able to obtain information.

LPA reached out to Regional Center of East Bay Quality Assurance Specialist (QS) assigned to the facility regarding the facility staffing ratio. QS stated that for 5 residents the facility should have 246 hours of staffing. QS also stated that for 6 residents of which 5 residents attending program 2 days/week, the minimum staffing hours/week is 248.

Based on interviews and review of staffing schedule and due to LPA not able to obtain information from 3 residents, the above 2 allegations are unsubstantiated.

Allegation: Staff failed to treat resident with dignity and respect.
Reporting party stated S1 cussed resident R1.

.....continued on 9099C (page 4)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20230619153702
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: REMINGTON CARE HOME #2
FACILITY NUMBER: 019200148
VISIT DATE: 12/17/2024
NARRATIVE
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Page 4

Nine (9) staff (S1, S2, S3, S5, S6, S7, S8, S10, SH) were interviewed and of this 9, only 1 stated S1 cussed R1. The other 8 staff stated not observing staff being disrespectful to any residents. Of 3 residents interviewed, 2 stated staff are respectful while the other 1 stated hearing noises when he was in his room but does not know what was going on. Based on interviews and due to LPA not able to obtain information from 3 residents, the allegation is unsubstantiated.

Allegation: Facility failed to maintain a comfortable room temperature.
During investigation and inspection, LPA observed the facility temperature was within Regulations range. LPA also observed electric fans in residents’ rooms and a portable air conditioning unit in the living room.

Nine (9) staff (S1, S2, S3, S5, S6, S7, S8, S10, SH) were interviewed and of this 9, only 1 stated the temperature inside the facility was 90+ degrees Fahrenheit. Two of the other staff stated the temperature was hot but there's a portable air conditioning unit and residents' rooms have electric fans. Three out of 6 residents stated facility temperature is never hot and they have electric fan in their rooms.

Based on interviews and observation and LPA unable to obtain information from the 3 residents, the allegation is unsubstantiated.

Based on the information obtained during the course of investigation and LPA unable to obtain information from 3 residents due to medical diagnosis, the above 6 allegations are closed are unsubstantiated.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7