019200164-7-19-2022-15-AS-KHOS-CHTLPR-20220831085621

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200164
Report Date: 07/19/2022
Date Signed: 07/19/2022 06:31:22 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
03/12/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20200312114218

FACILITY NAME:	HAYWARD HOLY INFANT RES. CARE FAC. II		FACILITY NUMBER:	019200164
ADMINISTRATOR:	SIMPORIANA P. JUGARAP		FACILITY TYPE:	735
ADDRESS:	1836 FLORIDA STREET		TELEPHONE:	(510) 887-0408
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	6	CENSUS: 6	DATE:	07/19/2022
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Simporiana Jugarap/Administrator		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Neglect/lack of supervision resulting to resident (R2) touching and kissing another resident's (R1) private area.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with Simporiana. administrator, and Bryan Ray Peneranda, lead staff.

It was alleged that R2 touched and kissed R1's private area, and that although the activity was consensual, it could be a result from facility's neglect/lack of supervision.

During the course of investigation, LPA obtained copies of residents' LIC602 Physician's Reports, Indvidual Program Plan, Individual Service Plan and Special Incident Report. LPA interviewed staff (S1, S2, S3, S4 and administrator), R2's case manager (CMT), individual (W2) who has known R1, and residents (R1, R2, R4 and R5).

...continued next page

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

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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Control Number 15-AS-20200312114218

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: HAYWARD HOLY INFANT RES. CARE FAC. II	FACILITY NUMBER: 019200164
	VISIT DATE: 07/19/2022

NARRATIVE

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R1 stated that they (R1 and R2) are friends and that R2 did not touched nor kissed R1's private area. W2 who had worked with R1 does not believe that the act of touching and kissing occurred because there's always staff in the facility. All four staff (S1, S2, S3 and S4) and administrator confirmed that R1 and R2 are friends and the act of touching and kissing of R1 private area is not likely to happen because there's always staff who observe the residents. R2 denied touching and kissing R1's private area.

Based on the information obtained, the allegation is unsubstantiated. .A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of report provided to Simporiana Jugarap.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC9099 (FAS) - (06/04)

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