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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200170
Report Date: 08/19/2021
Date Signed: 08/19/2021 12:42:26 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
08/12/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20210812153857
FACILITY NAME:MARCELO'S CARE HOME #3FACILITY NUMBER:
019200170
ADMINISTRATOR:BERNABE, SHIRLEY MFACILITY TYPE:
735
ADDRESS:3532 MILLER COURTTELEPHONE:
(510) 487-2397
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
08/19/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Doreen CamaraTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff unlawfully evicted a client while in care
INVESTIGATION FINDINGS:
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On 08/19/2021 , Licensing Program Analysts (LPA) L. Ibo and J. Sampair conducted an unannounced visit to deliver the findings for the above allegation. LPAs spoke with S2, Administrator is not available but LPA called to informed her the reason for the visit.

During investigation, C1 was taken to the hospital on 08/09/2021 ,hospital was trying to discharge the C1 back to the facility on 8/11/2021 but facility refused to take the client back. LPA L. Ibo conducted interviews and record reviews. Administrator admitted that she did not take C1 back to the facility. On 8/13/2021, C1 is back at the facility.

Continue to LIC9099C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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 3
Control Number 15-AS-20210812153857
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: MARCELO'S CARE HOME #3
FACILITY NUMBER: 019200170
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2021
Section Cited
CCR
80068.5(a)
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80068.5 Eviction Procedures (a).... the licensee may, upon 30 days written notice to the client, evict the client only for one or more of the following reasons.....

This requirement is not met as evidence by:
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Administrator need to create a plan on accepting clients back from the hospital. This plan will need to be submitted to LPA on POC date.
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Based on interview and records review, Administrator did not accept client back at the facility when hospital was trying to discharged C1 which posed an immediate Health, Safety, and Personal Rights 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: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20210812153857
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: MARCELO'S CARE HOME #3
FACILITY NUMBER: 019200170
VISIT DATE: 08/19/2021
NARRATIVE
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The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Exit interview conducted with Administrator & S2 Appeals rights and copy of report given.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3