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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200520
Report Date: 10/09/2025
Date Signed: 10/09/2025 11:24:41 AM

Substantiated


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
09/30/2025 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20250930163658
FACILITY NAME:JAYAR HOMEFACILITY NUMBER:
019200520
ADMINISTRATOR:ALCANTARA, MARIAFACILITY TYPE:
735
ADDRESS:576 JAYAR PLACETELEPHONE:
(510) 324-8343
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:4CENSUS: 4DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH: Kevin Braud, LicenseeTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff do not ensure resident's medications are properly stored.
INVESTIGATION FINDINGS:
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On 10/9/2025 at 8:40 AM, Licensing Program Analysts (LPAs) K. Nguyen and Y.Brown conducted an unannounced complaint visit and met with staff (S1). LPAs explained the purpose of the visit with staff. Later Licensee Kevin Braud arrived at a later time. LPAs conducted interviews & record reviews and delivered investigation findings to Licensee.

During investigation, LPAs reviewed the following documents from licensee – Residents’ roster, Personnel Record (LIC500) / Work Schedules, and LPAs toured the facility. LPAs conducted staff interviewed.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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 5
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
09/30/2025 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20250930163658

FACILITY NAME:JAYAR HOMEFACILITY NUMBER:
019200520
ADMINISTRATOR:ALCANTARA, MARIAFACILITY TYPE:
735
ADDRESS:576 JAYAR PLACETELEPHONE:
(510) 324-8343
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:4CENSUS: 4DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH: Kevin Braud, LicenseeTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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2
3
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9
Staff handles residents in a rough manner.
Staff do not ensure facility is free of clutter.
INVESTIGATION FINDINGS:
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On 10/9/2025 at 9:00 AM, Licensing Program Analysts (LPAs) K. Nguyen and Y.Brown conducted an unannounced complaint visit and met with staff (S1). LPAs explained the purpose of the visit with staff. LPAs conducted interviews & record reviews and delivered investigation findings to ADM.

During investigation, LPAs reviewed the following documents from ADM – Residents’ roster, Personnel Record (LIC500) / Work Schedules and LPAs toured the facility. LPAs conduced staffs and residents interviewed.

Upon entry, LPAs observed that there was no clutter in the hallway. LPAs observed that the passageways are free of clutter. LPAs observed that there was no clutter blocking emergency exits. LPAs toured the facility including but not limited to residents rooms, hallways, garage, kitchen area and resident restrooms.

Continued on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250930163658
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: JAYAR HOME
FACILITY NUMBER: 019200520
VISIT DATE: 10/09/2025
NARRATIVE
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Allegation: Staff handles residents in a rough manner.

Investigation Finding: Unsubstantiated

During staff interviews with staff: interview with staff one (S1) revealed that they have not witnessed or heard any staff handling residents in a rough manner. Interview with staff two (S2) stated that they have not witnessed or heard any staff handling residents in a rough manner. Interview with S3 revealed that they have not witnessed or heard any staff handling residents in a rough manner. S4 interview revealed that they have not witnessed or heard any staff members handling residents in a rough manner. Interview with resident one (R1) through translator app revealed that they have not experienced any staff members handling them in a rough manner.

Allegation: Staff do not ensure facility is free of clutter.


Investigation Finding: Unsubstantiated

During staff interviews with staff: Interview with S1 revealed that they have not experienced having clutter in the facility. S2 stated that they have not experienced having clutter in the facility. Interview with S3 revealed that they have not experienced clutter in the hallways. S4 interview revealed that they have not witnessed clutter at the facility. Interview with R1 through translator app revealed that they have not witnessed any clutter in the hallways at the facility.

Based on interviews conducted, the above 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.

There is no deficiency noted.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20250930163658
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: JAYAR HOME
FACILITY NUMBER: 019200520
VISIT DATE: 10/09/2025
NARRATIVE
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Allegation: Staff do not ensure resident's medications are properly stored.

Investigation Finding: Substantiated

S1 stated that in the medication cart the drawers are labeled with each resident’s names on them. S1 stated that they separate all the medication by resident’s name and place it in the drawer that matches the residents’ name in the medication cart. LPAs observed that some of the resident’s medication were wrongly placed in another resident’s section in the medication cart. S1 stated that “the placement of medication in the wrong section was a mistake.”



Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights, and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250930163658
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: JAYAR HOME
FACILITY NUMBER: 019200520
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2025
Section Cited
CCR
80075(k)
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80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored:
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By POC date, the Administrator agrees to remove the medication that is wrongly placed in another residents section in the medication cart and place the medication in the correct residents section and send photo proof to CCLD.
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Based on observation, the licensee did not comply with the section cited above by having resident’s medication wrongly placed in another resident’s section in the medication cart.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5