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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200705
Report Date: 07/21/2022
Date Signed: 07/21/2022 11:09:02 AM

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
05/06/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220506134144
FACILITY NAME:FULTON CAREFACILITY NUMBER:
019200705
ADMINISTRATOR:OCAL, GLENFACILITY TYPE:
735
ADDRESS:29024 RUUS ROADTELEPHONE:
(510) 887-6026
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:14CENSUS: 11DATE:
07/21/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Theresa Abernathy, StaffTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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On 7/21/22 at 10:35am, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegation and delivered investigation findings. LPA explained the purpose of the visit with staff and on the phone with Administrator. Administrator authorized staff to sign the report.

The Department has investigated this allegation and per record review and interviews found that the subjected client R1 currently does not have a conservator. R1 has rights to make decisions. R1 signed the agreement of terminating tenancy and left facility on 5/3/2022. R1 was unable to be located and has no contact information provided by Administrator or Social worker. The department was unable to interview R1 for additional information.

Continue LIC9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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-20220506134144
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: FULTON CARE
FACILITY NUMBER: 019200705
VISIT DATE: 07/21/2022
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

No deficiency cited. Exit interview conducted with staff and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2