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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200682
Report Date: 04/10/2024
Date Signed: 04/10/2024 11:12:02 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
02/13/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240213151658
FACILITY NAME:ELDRIDGE CARE HOMEFACILITY NUMBER:
019200682
ADMINISTRATOR:DIZON, MILLICENT RFACILITY TYPE:
735
ADDRESS:26601 ELDRIDGE AVENUETELEPHONE:
(510) 397-2056
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:6CENSUS: 6DATE:
04/10/2024
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Millicent DizonTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Due to lack of supervision, resident hit another resident


INVESTIGATION FINDINGS:
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On 4/10/2024 at around 10 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver finding on the above allegation and met with xxx. LPA explained to xxx the purpose of the visit.

During the course of investigation, LPA conducted 10-day visit and interviewed Staff 1 (S1) and Staff 2 (S2) on 2/21/2024. On 2/29/2024, LPA interviewed Client 1 (C1) and Client 2 (C2).

Based on interviews conducted with S1 and S2, C1 was inside the bathroom when C6 came knocking on the bathroom door on 2/2/2024. When C1 opened the door screaming at C6, C6 pulled C1’s hair. Staff then intervened and separated C1 and C2.

continuation Lic 9099C


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
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 5
Control Number 15-AS-20240213151658
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: ELDRIDGE CARE HOME
FACILITY NUMBER: 019200682
VISIT DATE: 04/10/2024
NARRATIVE
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Interview with C1 reveals that C1 was inside the bathroom when C6 came knocking on the bathroom door. C1 states C6 was knocking on the door non stop eventhough C6 was told that C1 was inside. C1 states that the door was locked and when C1 opened the door, C6 pulled C1's hair, pulled and ripped C1's shirt and that C1 sustained scratches on the arm.

C6 states that C6 needed to use the bathroom urgently. When C1 opened the door screaming at C6, C6 states that C6 pulled C1’s hair and ripped C1’s shirt. C1 then pulled C6’s hair back then the staff came to intervene.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D.

A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/13/2024 and conducted by Evaluator Luisa Fontanilla
COMPLAINT CONTROL NUMBER: 15-AS-20240213151658

FACILITY NAME:ELDRIDGE CARE HOMEFACILITY NUMBER:
019200682
ADMINISTRATOR:DIZON, MILLICENT RFACILITY TYPE:
735
ADDRESS:26601 ELDRIDGE AVENUETELEPHONE:
(510) 397-2056
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:6CENSUS: 6DATE:
04/10/2024
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Millicent DizonTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Due to lack of supervision, resident went into the bathroom while another resident was in there

Staff are not giving resident medications
INVESTIGATION FINDINGS:
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On this day, LPA Luisa Fontanilla arrived unannounced to deliver finding for the above allegations and met with Millicent Dizon. LPA explained to Dizon the purpose of the visit.

Staff interviewed state C1 would always lock the bathroom door whenever C1 uses it. C6 denied going inside the bathroom while C1 was inside as the door was locked. C1 confirmed with LPA that C1 would always lock the door whenever using the bathroom.

Based on C1’s Medication Administration Record (MAR) and interviews conducted, C1 has a medication that C1 takes 3x a day. Since C6 goes to the day program, C6 gets the noon time dose when C6 comes back to the facility at a later time. The only time C1 misses the medication is when C6 goes out with a friend and comes back to the facility late. Staff interviewed state C1 was advised to make sure to take medication before going out which staff say has been working.

continuation on Lic 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20240213151658
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: ELDRIDGE CARE HOME
FACILITY NUMBER: 019200682
VISIT DATE: 04/10/2024
NARRATIVE
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Based on interviews conducted, the above allegations are unsubstantiated.

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

There are no deficiencies issued. A copy of this report was provided to the Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240213151658
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: ELDRIDGE CARE HOME
FACILITY NUMBER: 019200682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2024
Section Cited
CCR
80087(a)
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80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
Based on interviews conducted, staff failed to intervene immediately when C1 and C2 were arguing which resulted to both clients pulling each other’s hair.
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The Administrator has provided and will continue to provide extra staffing hours to ensure safety of clients at the facility. Started providing extra hours on 4/11/2024. Updated Lic 500 will be sent to CCL by Friday, 4/12/2024.
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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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5