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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200746
Report Date: 01/23/2025
Date Signed: 01/23/2025 02:54:50 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
02/07/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20240207133010
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:
01/23/2025
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jeff Magadia, Care StaffTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff inappropriately handled resident in care.
INVESTIGATION FINDINGS:
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On 1/23/25 at 1:45p.m. Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced visit to deliver the findings for the above complaint allegation. LPA met with Care Staff, Jeff Magadia. LPA spoke with Administrator; Reynante (Ray) Bansil (ADM) via phone and explained the purpose of the visit. ADM gave permission to Jeff to sign the report, due to ADM is out sick.

Allegation: Staff inappropriately handled resident in care: Unsubstantiated

LPA conduced staffs interviewed, interviewed witness (w) and attempted to interview C1. LPA reviewed C1 record of admission agreement, physician's report, care plan, IPP, any RCEB assessments, and emergency information.

Report Continued on LIC 9099c...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
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-20240207133010
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: 01/23/2025
NARRATIVE
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S1 stated C1 have a behavior of being aggressive and started to move C1 hands and started yelling, then takes all C1 clothes off. C1 gets aggressive when C1 saw W because C1 was not used to being picked up by W. When C1 walked toward the door S2 noticed C1 started to move C1 hands and started yelling. That was when S2 knows that C1 will start taking of C1 clothes and becomes very agitated. The facility worked with C1 behaviorist and they had a routine for C1. S2 and S3 stated they tried to keep C1 calm and redirected C1, but when the door opens and C1 saw W that’s when C1 started to have the agitated behaviors. S2 and S3 was trying to help C1 from being violent and drop to the floor. S2 was hold C1 shirt down and S3 was trying to keep C1 pant up. C1 drop to the floor and started yelling and kicking. W stated that W was standing outside and saw that S2 and S3 was hold down C1 and W stated that W assume that they are hurting C1.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.

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.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2