019200266-5-1-2023-15-AS-KHOS-CRFQF8-20230502120730

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200266
Report Date: 04/28/2023
Date Signed: 05/01/2023 09:11:49 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
04/21/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20230421120529

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:	04/28/2023
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Kisha Baily, Care Staff		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Facility staff did not report an unusual incident in a timely manner.

INVESTIGATION FINDINGS:

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On 4/28/23 at 2:10 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Kisha Baily, Care Staff and explained the purpose of the visit and spoke to adininstrator Norman Goolsby via telephone..

During the course of investigation, LPA interviewed 4 staff and administrator and toured the facility. LPA also reviewed C1’s needs and services plan dated 1/16/23, physician's report dated 11/15/22 and IPP dated 2/05/22.

LPA confirmed that C1 no longer lives at the facility. Based on documentation reviewed C1 was able to leave the facility unassisted. Interviews confirmed that C1 left the facility on 2/7/23 telling staff he was going to visit his dad for a few days.

**Report conitunues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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-20230421120529

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: 04/28/2023

NARRATIVE

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***Report continues from LIC9099***

On 2/10/23 facility staff discovered a note in C1’s room stating he was moving out. Also, on 2/10/23 C1 called the administrator to inform him that he would not be returning to the facility. On 2/11/23 administrator filed a Special Incident Report with CCL reporting this series of incidents.

This agency has investigated the complaint alleging that facility staff did not report an unusual incident in a timely manner. We have found the allegation is unsubstantiated. 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.

Exit interview conducted, a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

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