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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200667
Report Date: 11/29/2022
Date Signed: 11/29/2022 09:35:59 AM

Substantiated


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
04/01/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210401101703
FACILITY NAME:THRIVE ADULT RESIDENTIAL CAREFACILITY NUMBER:
019200667
ADMINISTRATOR:INGRAM, TERRIFACILITY TYPE:
735
ADDRESS:601 ELYSIAN FIELDS DRIVETELEPHONE:
(510) 878-1921
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY:6CENSUS: 6DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Maria Gracia Golitzen, Assistant AdministratorTIME COMPLETED:
09:50 AM
ALLEGATION(S):
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Administrator failed to report change in criminal record status
INVESTIGATION FINDINGS:
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On 11/29/2022 at 8:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver findings in regards to the allegation above. LPA met with staff, Ronaldo Garcia and informed him the reason for the visit. Assistant Administrator, Maria Gracia Golitzen arrived 30 minutes later.

During the course of investigation, LPA interviewed staff and complainant. LPA reviewed and obtained staff schedule and police report. Interview with staff revealed that S1 needed to post bail. RO (Regional Office) did not receive an incident report regarding S1's changes in criminal record status.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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-20210401101703
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: THRIVE ADULT RESIDENTIAL CARE
FACILITY NUMBER: 019200667
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2022
Section Cited
CCR
80061(b)
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Reporting Requirements. Upon the occurrence...of any of the events specified in (1) below, a report shall be made to the licensing agency...
This requirement is not met as evidence by:
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Administrator has agreed to review reporting requirements and submit a written statement of understanding to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not reporting S1's changes in criminal record status which poses an immediate health and safety risk to the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2