019200658-5-16-2024-15-AS-KHOS-D5YGLB-20240606052605

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200658
Report Date: 05/16/2024
Date Signed: 05/16/2024 11:32:24 AM

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
04/23/2024 and conducted by Evaluator Luisa Fontanilla

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240423120112

FACILITY NAME:	EVELYN MANOR		FACILITY NUMBER:	019200658
ADMINISTRATOR:	MONTECLAR, IRENE		FACILITY TYPE:	735
ADDRESS:	1076 TULANE AVE		TELEPHONE:	(510) 878-2352
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94579
CAPACITY:	4	CENSUS: 4	DATE:	05/16/2024
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Charito Aberle		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff handled resident in a rough manner

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On this day at around 10:40 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to interview Staff 3 (S3) and deliver finding for the above allegation. LPA met with Charito Aberle. The Administrator was informed over the phone about the visit. The Administrator authorized Aberle to sign the report.

On 4/23/2024, LPA conducted pre investigation with Reporting Party (RP). On 4/24/2024, LPA conducted 10-day visit, obtained records and interviewed Staff 1 (S1) and Staff 2 (S2). On 4/26/2024, LPA conducted a collateral visit and interviewed Witness 1 (W1) and Witness 2 (W2). On 5/16/2024, LPA interviewed S3.

Based on interviews conducted with W1 and W2, both state that they observed S2 being rough and grabbing C1 to get C1 off the van.

continuation on Lic 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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-20240423120112

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: EVELYN MANOR	FACILITY NUMBER: 019200658
	VISIT DATE: 05/16/2024

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

Based on interviews conducted with Staff 1 (S1), S1 received a call from the day program staff who picked up C1 saying that C1 was transported back to the facility early due to C1 refusing to get off the van when at the day program parking lot. And that the staff need assistance with C1 because C1 refused to get off the van. S1 went to the van to take C1 back to the facility but C1 attempted to hit S1. S1 then called S2 to assist. S2 came and assisted C1 get off the van and went back to the facility without any problem. S1 states C1 gets along with S2. S1 denied observing or knowing any staff hurting, harming or mistreating any client. S1 states police officers arrived at the facility to check on C1 and left.

S2 states that S1 called to assist with C1 because C1 was transported back to the facility. S2 states S2 went to the van, moved C1’s feet together, put one arm on C1’s shoulder and the other arm on C1’s underarm and told C1 to stand up. S2 states C1 stood up and walked back to the facility. S2 denied hurting, harming or mistreating any client. S2 states that S2 has been C1’s primary caregiver for 5 years and that they get along.

While at the facility, LPA checked on C1's back of neck and did not observe any bruise or mark.

On 5/16/2024, LPA interviewed S3 who denied knowing or witnessing any staff mistreat, harm or hurt any client.

All staff interviewed denied knowing or observing any staff harming, hurting or mistreating any client.

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.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2