019200266-8-26-2022-15-AS-KHOS-CJ9LC5-20220914083746

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200266
Report Date: 08/26/2022
Date Signed: 08/26/2022 11:59:16 AM

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
06/23/2022 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20220623140511

FACILITY NAME:	STACY STREET FACILITY		FACILITY NUMBER:	019200266
ADMINISTRATOR:	NORMAN GOOLSBY SR.		FACILITY TYPE:	735
ADDRESS:	4961 STACY STREET		TELEPHONE:	(510) 638-8460
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94605
CAPACITY:	6	CENSUS: 5	DATE:	08/26/2022
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Norman Goolsby, Sr, Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Resident is being discriminated against
Staff refused to help resident while in care
Staff did not provide adequate food service
Facility is unkempt

INVESTIGATION FINDINGS:

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On 8/26/22 at 11:45 A.M., Licensing Program Analyst (LPA) Greg Clark arrived unannounced visit to deliver the findings for the above allegations. LPA met with Administrator Norman Goolsby, Sr and explained the purpose of the visit.

During the course of investigation, LPA toured facility and found it in good repair. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Food supply is adequate for residents in care. LPA also reviewed menus which show a good variety of healthy food items. LPA reviewed the Medication Administration Records (MARS) and found that they were filled out correctly. LPA reviewed the staff roster and found that it matched the Guardian report for the fingerprint associations to the facility. The resident roster for the facility included the reporting party.

***cont'd on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

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-20220623140511

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: STACY STREET FACILITY	FACILITY NUMBER: 019200266
	VISIT DATE: 08/26/2022

NARRATIVE

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**report cont'd from LIC9099***

LPA interviewed Care Staff Kisha Baily and 2 residents (R1 & R2). During the resident interviews R1 and R2 reported no issues with the food at the facility and both stated that the food was "pretty good." Both also reported having no issues with the staff at the facility and that the staff were always ready to help them if needed. Ms. Baily reported as having no issues with the residents at the facility and that no residents have ever complained to her about other staff.

This agency has investigated the complaints alleging: resident is being discriminated against, staff refused to help resident while in care, staff did not provide adequate food service and facility is unkempt.

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

Exit interview conducted, a copy of this reported provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC9099 (FAS) - (06/04)

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