019200695-12-27-2023-15-AS-YFLS-D2WVQQ-20240229153842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200695
Report Date: 12/27/2023
Date Signed: 12/27/2023 03:07:23 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
12/20/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20231220151542

FACILITY NAME:	GOOD SHEPHERD VISTA		FACILITY NUMBER:	019200695
ADMINISTRATOR:	KOO, HASMIN		FACILITY TYPE:	740
ADDRESS:	5472 FOOTHILL BLVD		TELEPHONE:	(510) 534-5734
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94601
CAPACITY:	22	CENSUS: 19	DATE:	12/27/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Hasmin Koo, Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff did not safeguard resident's property.

INVESTIGATION FINDINGS:

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On 12/27/23 at 1:45 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegation above. LPA met with Hasmin Koo, Administrator and explained the purpose of the visit.

During the visit LPA interviewed S1. S1 stated that the staff at the facility deliver mail to R1 which includes his personal and incidental allowance checks. S1 further stated that once R1 has his check he leaves the facility the same day to cash his check. The facility does not handle cash resources for the residents.

***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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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Control Number 15-AS-20231220151542

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: 12/27/2023

NARRATIVE

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***report continues from LIC9099***

The facility does laundry for the residents on a daily basis for most residents. R1 has his own laundry basket which the staff pick up upon request in the evening and return in the morning. Upon admission the facility puts the residents name in all of their clothing to help identify what items belong to what residents. R1 often accuses other residents of wearing his clothing and staff have to show him the name in the clothing to prove the clothing is not his.

LPA reviewed R1’s file. R1 has been at the facility since 11/07/2022 and is able to leave the facility unassisted. The facility manages R1’s medication. R1 needs help with most of his activities of daily living.

LPA also interviewed R1. R1 was able to tell LPA that he gets a $30 check weekly and cashes the checks at a check cashing place and buys cigarettes and personal items. R1 stated “they take everything I got” but was unable to provide LPA with any details.

This agency has investigated the complaint alleging that facility staff did not safeguard resident's property. We have found that the complaint was 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.

Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

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