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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200267
Report Date: 05/23/2022
Date Signed: 05/23/2022 04:25:18 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
08/25/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200825115443
FACILITY NAME:OAK HOME AT NILES GROVEFACILITY NUMBER:
019200267
ADMINISTRATOR:CLAY, CHANDREVEFACILITY TYPE:
735
ADDRESS:35543 NILES BLVD.TELEPHONE:
(510) 818-0650
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:6CENSUS: 5DATE:
05/23/2022
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Chandreve Clay, AdministratorTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Facility staff verbally abuses resident.
Facility staff do not treat resident with respect.
Facility staff threatened resident.
INVESTIGATION FINDINGS:
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On 5/23/2022 at 12:40PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Administrator, Chandreve Clay.

During the course of investigation, LPA interviewed 5 clients, 6 staff, and complainant. LPA also obtained and reviewed client's IPP, ISP, and Physician's report.

Facility staff verbally abuses resident.
Interview with clients and staff revealed that no one witness staff verbally abused clients at the facility. Staff stated they did not witness any staff speaking inappropriately to a client.

(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
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-20200825115443
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: OAK HOME AT NILES GROVE
FACILITY NUMBER: 019200267
VISIT DATE: 05/23/2022
NARRATIVE
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Facility staff do not treat resident with respect.
Interview with clients revealed that clients likes the staff and gets a long with the staff. Clients stated they did not see any staff mistreating clients.

Facility staff threatened resident.
Interview with clients and staff revealed that no staff threatened clients.

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

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2