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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200746
Report Date: 07/25/2025
Date Signed: 07/25/2025 01:31:23 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
04/29/2025 and conducted by Evaluator Ardalan Gharachorloo
COMPLAINT CONTROL NUMBER: 15-AS-20250429125904
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: 5DATE:
07/25/2025
UNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Reynante Bansil, AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff threatened resident.
Resident is not being accorded dignity in their personal relationships with staff.
INVESTIGATION FINDINGS:
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On 07/25/2025 at 11:50 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver findings regarding the allegations listed above. LPA met with Reynante Bansil, Administrator and explained the purpose of the visit.

During the course of the investigation, LPA interviewed three staff (S1-S3), R1, and W1. In addition, LPA reviewed staff schedule and training, LPA also reviewed S2,S3 files and R1’s file including current care plan, Physician report, MARs and admission agreement.

Allegation: Staff threatened resident -Unsubstantiated.

Interviews with S1 and S2 indicated that staff do not physically intervene with residents during drop-off unless there is a specific need. S1 stated, “Staff generally wait at the door and observe unless the client signals, they need help.

***CONTINUE ON 9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
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 3
Control Number 15-AS-20250429125904
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HAVEN HOME
FACILITY NUMBER: 019200746
VISIT DATE: 07/25/2025
NARRATIVE
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***CONTINUE FROM 9099**

No one is instructed to physically force residents out of a vehicle.” S2 denied using threatening language and added, “I remember Antonin hesitating that day, but I calmly asked if he needed help. There was no threat or aggressive tone used.”

W1, who was present during the incident, stated that a staff member from the facility spoke in Tagalog, and while W1 could not definitively confirm that the staff threatened R1. W1 stated, “I heard her say something quickly in Tagalog—not sure if it sounded angry or not. LPA also interviewed S3 who stated” I didn’t see S2 grab him or force him out, and I wouldn’t say she was yelling.” R1, when asked about the event, stated, “I don’t remember anything bad. I was just tired that day.”

Allegation: Resident is not being accorded dignity in their personal relationships with staff-Unsubstantiated.

W1 stated that R1 appeared reluctant to get out of the car upon returning from the day program, and W1 wanted to ensure everything was okay with the interaction between staff and R1. LPA interviewed S1 who explained that the facility provides regular training to staff on respectful communication and maintaining client dignity. S1 stated, “We make it clear that residents should be always treated with patience and care. If any staff spoke inappropriately, it would be addressed immediately, and we have not had those incidents at this facility.”

S2 stated, “R1 moves at his own pace sometimes. We don’t pressure him—just to offer help if he wants it. He’s treated with respect like everyone else.” R1 shared during the interview, “They’re nice to me. I don’t have problems with staff.” R1 did not express any discomfort or concerns related to how he is treated at the facility.

***CONTINUE ON 9099C***

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250429125904
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HAVEN HOME
FACILITY NUMBER: 019200746
VISIT DATE: 07/25/2025
NARRATIVE
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***CONTINUE 9099C***

This agency has investigated the above allegations. We have found that the allegations were 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 conducted, a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3