<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200655
Report Date: 09/21/2021
Date Signed: 09/21/2021 01:50:09 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
11/06/2019 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20191106160539
FACILITY NAME:ALOHA RESIDENTIAL CARE INCFACILITY NUMBER:
019200655
ADMINISTRATOR:KATELYN SALVADORFACILITY TYPE:
735
ADDRESS:34706 WILLIAMS WAYTELEPHONE:
(510) 921-4949
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
09/21/2021
UNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Katelyn SalvadorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff inappropriately restrained resident
Facility staff forced resident to take medication
Facility staff mismanaged resident's medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/21/2021 at approximately 1:39pm Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to conduct a continuing complaint investigation. LPA met with Administrator Katelyn Salvador and explained the purpose of the visit.

During the course of the investigation, LPA interviewedr five residents (C1, C2, C3, C4, and C5), one resident advocate of C1, one family member of C1, Licensee Nicholas Marcelo, Katelyn Salvador, and three staff (S1, S2, and S3). LPA reviewed & obtained physicians reports, IPPs, MAR, staff contact list, medication order, staff schedule, resident roster, and incident report. Per an incident report that was cross-reported to CCLD, the allegations are specific to C1 on October 21, 2019. When interviewed by LPA, Resident C1, three staff

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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-20191106160539
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: ALOHA RESIDENTIAL CARE INC
FACILITY NUMBER: 019200655
VISIT DATE: 09/21/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
that were working on October 21, 2021, Licensee Nicholas Marcelo, and Katelyn Salvador all denied the allegations occurred. Additionally, LPA reviewed MAR and medication order which indicated C1 was given the correct dosage of medication.

The Department has investigated these allegations and based upon LPA's observations, interviews conducted, and records reviewed, the allegations are found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations has occurred.

Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2