019200664-6-20-2024-15-AS-KHOS-D6JRH8-20240624130155

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200664
Report Date: 06/20/2024
Date Signed: 06/20/2024 01:12:15 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
06/17/2024 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20240617080839

FACILITY NAME:	COLONIAL ACRES RESIDENTIAL CARE HOME		FACILITY NUMBER:	019200664
ADMINISTRATOR:	MAGALLONES, ADELIZA R		FACILITY TYPE:	740
ADDRESS:	18905 STANDISH AVENUE		TELEPHONE:	(510) 276-0939
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	20	CENSUS: 15	DATE:	06/20/2024
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Adeliza Magallones/Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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9

Licensee did not keep resident's (PR) personal information confidential.

INVESTIGATION FINDINGS:

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At 12:05 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Adeliza Magallones, administrator, and informed the reason for visit. LPA spoke over the phone with John Ronald Olivarez, licensee.

During investigation, LPA obtained copy of LIC9020 Register of Facility Clients/Residents. LPA interviewed licensee who stated he did not disclose the name of prospective resident (PR) but disclosed the health information to prospective room mate (R1) and R1''s family member, but PR was never admitted to the facility. LPA also interviewed the administrator who stated that PR was not admitted to the facility. Review of LIC9020 showed PR is not listed.

Based on information obtained and FR is not admitted to the facility, the allegation is unsubstantiated.

No deficiency cited. Exit interview conducted and copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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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