<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200188
Report Date: 06/18/2024
Date Signed: 06/18/2024 02:01:57 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
06/17/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20240617154153
FACILITY NAME:DEBBIE'S HOME AWAY FROM HOME IIIFACILITY NUMBER:
019200188
ADMINISTRATOR:DEBRA PICKENSFACILITY TYPE:
735
ADDRESS:8949 SENECA STREETTELEPHONE:
(510) 549-6001
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY:6CENSUS: 1DATE:
06/18/2024
UNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Omar Walker, staff TIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared adults living at the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/18/2024 at 1:20 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger A. Gharachorloo arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with staff Omar Walker and called administrator Debra Pickens.

During the initial 10-day complaint visit. LPA interviewed staff and collected the admissions agreement for R1. S1 stated that they just "reopened" and started accepting residents again after taking a hiatus for two years. S1 said that the resident moved in on June 1st.

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

Exit interview conducted and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
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 1