019200250-9-30-2022-15-AS-KHOS-CJVKTT-20221004081139

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200250
Report Date: 09/30/2022
Date Signed: 09/30/2022 01:53:52 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
05/05/2022 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220505150257

FACILITY NAME:	MCCLURE CARE HOME		FACILITY NUMBER:	019200250
ADMINISTRATOR:	MUNIZ, SHIELHA C		FACILITY TYPE:	735
ADDRESS:	2903 MCCLURE STREET		TELEPHONE:	(510) 272-0104
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94609
CAPACITY:	25	CENSUS: 23	DATE:	09/30/2022
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Juliana Taburaza, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff not address change in resident condition.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 9/30/2022 at 10:10 AM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a subsequence complaint investigation visit in regard to the above allegation and delivered investigation findings. LPA met with staff and informed her the reason for visit. Administrator Juliana Taburaza arrived at a later time.

The Department has investigated this allegation and per records review and interviews, and found that C1’s particular health concern was addressed and indicated on the appraisal/needs and services plan dated on 11/18/2021 and 3/20/2022. Facility staff had documented it monthly.

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

No deficiency cited, exit interview conducted with Administrator, and a copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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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