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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200658
Report Date: 10/01/2025
Date Signed: 10/01/2025 01:03:07 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
09/24/2025 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20250924170341
FACILITY NAME:EVELYN MANORFACILITY NUMBER:
019200658
ADMINISTRATOR:MONTECLAR, IRENEFACILITY TYPE:
735
ADDRESS:1076 TULANE AVETELEPHONE:
(510) 878-2352
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY:4CENSUS: 4DATE:
10/01/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Irene Monteclar TIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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On 10/1/2025 at 9:00 am, Licensing Program Analysts (LPAs) K. Nguyen and Y Brown conducted an unannounced complaint visit and met with staff (ADM, 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, Residents; admission agreement, physicians’ report, needs & services plan, incident reports.

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

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
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 2
Control Number 15-AS-20250924170341
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: 10/01/2025
NARRATIVE
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Allegation: Staff handled resident in a rough manner.

Investigation Finding: Unsubstantiated

During investigation, LPAs interviewed Administrator(ADM) and staff: S1, S2, S3, and S4, and attempted to interview residents R1, R2 and R3. LPAs reviewed P&I and observed that all transactions are made through the facility provided credit card and no cash is involved. ADM stated that they use a facility provided credit card for all outings. During staff interviews, 4 out of 4 staff stated that they did not witness any staff mishandling the residents in a rough manner.

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: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2