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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200746
Report Date: 03/29/2022
Date Signed: 03/29/2022 12:18:03 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
02/02/2022 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20220202113337
FACILITY NAME:HAVEN HOMEFACILITY NUMBER:
019200746
ADMINISTRATOR:GONZALES-BANSIL, MAEFACILITY TYPE:
735
ADDRESS:8695 WICKLOW LANETELEPHONE:
(510) 220-6712
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:6CENSUS: 6DATE:
03/29/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Reynante Bansil, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not accommodating client's family to arrange outings with client.
Facility is not accommodating client's family to drop off items for client.
Facility failed to answer the phone in a timely manner.
Facility is not allowing visitors
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/9/2022 at 9:40 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct complaint investigation for the above allegations. Upon arrival LPAs were greeted by Edgardo Olandez. Administrator, Reynante Bansil later arrived at 10:00 AM.

During the complaint investigation, LPAs obtained information, reviewed records, collected documents, interviewed 2 clients and 4 staff.



REPORT CONTINUES ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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 3
Control Number 15-AS-20220202113337
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: HAVEN HOME
FACILITY NUMBER: 019200746
VISIT DATE: 03/29/2022
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
Allegation: Facility not accommodating client's family to arrange outings with client.

However, based on record review, LPAs observed facility are accommodating family members to take clients on outings. LPAs reviewed a sample of text from three client's family members making arrangements with S1 to take C1, C3, and C4 out. C1 stated C1 goes on outings and 4 of 4 staff stated C1, C2 and C3 are being taken out by family.

Allegation: Facility is not accommodating client's family to drop off items for client.

However, interview with C1 revealed C1's family relative dropped off food to C1. S2 confirmed C1's family relative dropped off food for C1.

Allegation: Facility failed to answer the phone in a timely manner.

However, based on interviews with 4 staff, 4 of 4 staff stated phones are answered promptly unless it indicates on the caller ID that it is a spam call. If clients are not available to receive a call, staff will take a message and write it on the whiteboard located in the kitchen next to the landline. 3 of 4 staff stated they give the message to clients. On 3/29/2022, LPAs observed a message for C1 to call a family relative every Friday as a reminder.

Allegation: Facility is not allowing visitors

However, based on record review, facility has been allowing visitation since March 2021. 2 of 2 clients stated they are allowed to have visitors.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3