<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200705
Report Date: 04/26/2023
Date Signed: 04/26/2023 10:55:51 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
10/26/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20211026102749
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: 13DATE:
04/26/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Theresa Abernathy/House Manager-Care StaffTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff (S1) is verbally abusive to client (C1).
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with House Manger Theresa Abernathy, and informed the purpose of visit. LPA called and spoke over the phone with Glen Ocal. administrator. Administrator gave permission to have Abernathy to sign and receive this report.

It was alleged that staff (S1) does not stop harassing client (C1). It was further alleged that S1 told C1 “Your day is coming soon and I'm going to be in the front seat watching."


.....continued on 9099C


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
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-20211026102749
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: 04/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 11/03/2021, LPA obtained copy of LIC9020 Register of Facility Clients/Residents, and interviewed staff (S1), administrator and 7 clients including C1. All 7 indicated S1 was not abusive to them. One of the 7 clients confirmed that S1 said, “Your day is coming soon and I'm going to be in the front seat watching." but it was said on a different context. C1 indicated that it was all about the other client who moved out, but C1 does not remember the context of what was said. S1 denied being abusive to C1 and other clients.

Based on information gathered during interviews, the allegation is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited,

Exit interview conducted, and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2