019200656-3-11-2022-15-AS-KHOS-CCS26K-20220322170717

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200656
Report Date: 03/11/2022
Date Signed: 03/11/2022 01:54:22 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
04/13/2020 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200413085109

FACILITY NAME:	JAY MAHLER RECOVERY CENTER		FACILITY NUMBER:	019200656
ADMINISTRATOR:	CLEARNISE P BULLARD		FACILITY TYPE:	772
ADDRESS:	15430 FOOTHILL BOULEVARD		TELEPHONE:	(510) 357-3562
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94578
CAPACITY:	16	CENSUS: 10	DATE:	03/11/2022
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Denise Garcia, Administrator		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Facility admitted a resident with a positive TB result
Facility does not provide a safe environment for clients
Facility lacks sufficient staffing to meet client's needs

INVESTIGATION FINDINGS:

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On 3/11/22 at 10:10am, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegations and deliver investigation findings. LPA explained the purpose of the visit with administrator.

Allegation: Facility admitted a resident with a positive TB result – Unsubstantiated
The Department has investigated this allegation and per records review and interviews, S2 stated that there had been one participant that had been admitted to the facility without a completed TB result during the subject time period. S2 reported the situation to the Regional Manager who intervened and had the participant removed from the facility. The name of the participant was not discovered.

Continue LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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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Control Number 15-AS-20200413085109

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: JAY MAHLER RECOVERY CENTER	FACILITY NUMBER: 019200656
	VISIT DATE: 03/11/2022

NARRATIVE

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Allegation: Facility does not provide a safe environment for clients – Unsubstantiated

The Department has investigated this allegation and per records review and interviews, S2 stated that staff found that participants were attempting to hide substances in the shrubbery outside of the library door, and immediately placed an alarm on it so that it may be monitored. S2 also stated that increased checks of the participants were made when they returned to the facility from the community. S2 stated that the issue was quickly brought under control. S3 stated the same thing as S2. One Participant (R6) and two family members (W1 and W2) at the subject time period were contacted by phone, they stated that they had no issue and felt facility was safe.

Allegation: Facility lacks sufficient staffing to meet client’s needs – Unsubstantiated

The Department has investigated this allegation and per interviews could not establish what services may not have been met. Multiple attempts were made to speak to RP to obtain specific information but Department received no response. R6, W1 and W2 stated that they received services they required. Current participants stating that they are receiving the services they require.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegations are unsubstantiated.

No deficiencies cited. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC9099 (FAS) - (06/04)

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