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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200544
Report Date: 05/05/2021
Date Signed: 05/05/2021 03:54:35 PM



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
11/25/2020 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20201125165732
FACILITY NAME:AIC RESIDENTIAL CARE FACILITY FOR THE ELDERLYFACILITY NUMBER:
019200544
ADMINISTRATOR:ALBERT LEANOFACILITY TYPE:
740
ADDRESS:23652 NEVADA ROADTELEPHONE:
(510) 314-0807
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 4DATE:
05/05/2021
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Helen Macatangay/LicenseeTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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-Residents not accorded privacy in telephone conversations.

-Staff do not allow residents to have a personal cell phone.
INVESTIGATION FINDINGS:
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On this day, May 5, 2021, Licensing Program Analyst (LPA) Delmundo spoke with Helen Macatangay, licensee, and informed the reason for call. LPA further informed that due Shelter in Place Order by the Governor and management directive to telework, LPA is delivering the findings to the allegations via televisit.

LPA conducted interviews on December 2, 2020, December 3, 2020 and December 7, 2020. Residents’ family members, staff (S1, S2 and S3), and residents (R2 and R3) were interviewed. S1, S2, S3 and former house manager said residents are accorded privacy in their telephone conversations which LPA confirmed with R2 and R3. Staff indicated residents are not prohibited from having cell phone. Information obtained revealed R4 has a cell phone. Although R2 has one, it was broken. S1 stated he accompanied R2 to phone service provider which collaborated with R2’s statement.


,,,,continued on 9099C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
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-20201125165732
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: AIC RESIDENTIAL CARE FACILITY FOR THE ELDERLY
FACILITY NUMBER: 019200544
VISIT DATE: 05/05/2021
NARRATIVE
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Based on the information obtained, the allegations are unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted and copy of this report provided via e-mail to Helen Macatangay.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2