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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200311
Report Date: 12/02/2021
Date Signed: 12/02/2021 02:55:02 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
01/04/2021 and conducted by Evaluator Gregory Clark
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210104090151
FACILITY NAME:THOMAS-ADAMS RESIDENTIAL CARE FACILITY, INC.FACILITY NUMBER:
019200311
ADMINISTRATOR:ALLISON K PASCHAL-HUNTERFACILITY TYPE:
735
ADDRESS:5152-5158 FOOTHILL BLVD.TELEPHONE:
(510) 533-3470
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:32CENSUS: 31DATE:
12/02/2021
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Matthew Thomas, LicenseeTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not assist resident with making a medical appointment
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/2/2021 at 1:45 PM Licensing Program Analysts (LPAs) G. Clark and L. Francisco arrived unannounced to deliver findings for the above allegations. LPAs met with Licensee Matthew Thomas and explained the purpose of the visit.

During the course of the investigation, LPA G. Clark obtained information, collected documents and interviewed 2 staff. It was alleged facility staff did not assist resident with making a medical appointment. Based on Interviews with 2 staff, resident's social worker is responsible for scheduling resident's medical appointment. No forthcoming information provided by reporting party. Therefore, LPAs were unable to prove whether facility is responsible for scheduling resident's appointment or resident's social worker.

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. Due to technical difficulties, a copy of report is being provided via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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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