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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200250
Report Date: 12/27/2022
Date Signed: 12/27/2022 03:36:04 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
12/22/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20221222160908
FACILITY NAME:MCCLURE CARE HOMEFACILITY NUMBER:
019200250
ADMINISTRATOR:MUNIZ, SHIELHA CFACILITY TYPE:
735
ADDRESS:2903 MCCLURE STREETTELEPHONE:
(510) 272-0104
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY:25CENSUS: 22DATE:
12/27/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Norman Luat, staff on duty TIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal belongings
INVESTIGATION FINDINGS:
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On 12/27/2022 at 11:00 AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct an initial 10-day complaint investigation regarding the allegation above. LPA met with S3 and informed him the purpose of the visit. S3 called S1 and S2 and left voicemail. S2 called back and spoke with LPA. LPA informed S2 the reason for visit, S2 stated that LPA can provide the copy of the report to S3.

During the course of investigation, LPA interviewed 5 clients and 3 staff. LPA also obtained and reviewed client files including but not limited to physician’s report, progress notes, care plan, and emergency information.

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

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
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 2
Control Number 15-AS-20221222160908
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: MCCLURE CARE HOME
FACILITY NUMBER: 019200250
VISIT DATE: 12/27/2022
NARRATIVE
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Interviewed with clients revealed that client was not missing their clothes. Based on the interview with clients the staff does not alter any of client’s clothes. Interviews with clients indicated that clients' clothes were not damaged or cut after clothes were cleaned by staff. Staff stated that clothes are wash once a week and after each of every client’s laundry the staff returned their belongings within couple of hours.

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 S3, and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2