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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200695
Report Date: 07/22/2022
Date Signed: 07/22/2022 03:50:32 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
06/09/2022 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20220609163420
FACILITY NAME:GOOD SHEPHERD VISTAFACILITY NUMBER:
019200695
ADMINISTRATOR:KOO, HASMINFACILITY TYPE:
740
ADDRESS:5472 FOOTHILL BLVDTELEPHONE:
(510) 534-5734
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:22CENSUS: 19DATE:
07/22/2022
UNANNOUNCEDTIME BEGAN:
03:31 PM
MET WITH:Hasmin Koo, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff sexually assaulted resident while in care.
INVESTIGATION FINDINGS:
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On 7/22/22 at 3:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver complaint findings for the allegation above. LPA met with Hasmin Koo and explained the purpose of the visit.

During the investigation LPA interviewed the Reporting Party (RP), 4 staff and 1 resident. LPA reviewed staff roster, staff schedule for June 2022, LIC624 for R1 dated 6/7/22 and R1’s facility file. LPA attempted to contact R1 through family member however no call was ever returned. Interviews conducted with the staff revealed that staff S1 and S2 assisted R1 when she fell out of bed on 6/06/22 at approximately 9:00 p.m. This is also documented on the LIC624 dated 6/7/22. The staff, S3, who allegedly assaulted the victim arrived at the facility on that day at 10:30 pm to work the overnight shift. S3 told LPA that he has never assisted anyone off the floor back into their bed.

***cont'd on 9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
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-20220609163420
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: GOOD SHEPHERD VISTA
FACILITY NUMBER: 019200695
VISIT DATE: 07/22/2022
NARRATIVE
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**report continues**

R1 no longer resides at the facility and has moved back with family.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2