019200459-9-23-2022-15-AS-KHOS-CKAQYH-20221017123511

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200459
Report Date: 09/23/2022
Date Signed: 09/23/2022 03:21:04 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
08/23/2022 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220823163634

FACILITY NAME:	EVERGREEN RESIDENTIAL CARE		FACILITY NUMBER:	019200459
ADMINISTRATOR:	OSUKA, ADA P.		FACILITY TYPE:	735
ADDRESS:	2292 N. LIVERMORE AVENUE		TELEPHONE:	(925) 487-1551
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94551
CAPACITY:	5	CENSUS: 3	DATE:	09/23/2022
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Ada Osuka, Administrator		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff yelled at resident.

INVESTIGATION FINDINGS:

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On 9/23/2022 at 2:40PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver findings in regards to the allegation above. LPA met with staff, Maria Arrieta.
Administrator, Ada Osuka arrived 15 minutes later.

During the course of investigation, LPA interviewed 3 clients and 3 staff. Interview with clients revealed that no staff yelled at clients. Interview with staff indicated that staff does not yell at clients and would redirect when clients have behaviors.

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

Exit interview conducted. A copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

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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