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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200750
Report Date: 09/30/2020
Date Signed: 09/30/2020 11:15:13 AM



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
09/22/2020 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20200922163412
FACILITY NAME:SCOTT VILLAFACILITY NUMBER:
019200750
ADMINISTRATOR:JONABELLE TOLENTINOFACILITY TYPE:
740
ADDRESS:1560 MIDDLE LANETELEPHONE:
(510) 782-7833
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:35CENSUS: 34DATE:
09/30/2020
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jonabelle Tolentino/Administrator TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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-Facility staff is not assisting resident (R1) with hygiene needs.

-Facility staff is not properly supervising resident (R1).

-Facility staff is mismanaging the resident's (R1) medication.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Alicia Delmundo and Jacob Williams called and spoke with Jonabelle Tolentino, administrator . LPA Delmundo explained that the reason for the call is to inform that a complaint has been received. LPA further explained that due to the Shelter in Place Order and management directive to telework, the notification is done via video conference.

LPAs obtained copies of resident rosters for June 2020, August 2020 and September 2020, and LIC500 Personnel Report. LPAs conducted interviews. LPAs interviewed Ms. Tolentino and staff (S1, S2, S3 and S4) who stated there's no resident with R1's name. Review of resident rosters confirmed staffs' statements.


........continued next page
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020
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-20200922163412
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: SCOTT VILLA
FACILITY NUMBER: 019200750
VISIT DATE: 09/30/2020
NARRATIVE
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Based on the information obtained during the course of investigation that R1 is not a resident of the facility, the allegations are closed as unfounded. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted and copy of this report provided to Ms, Tolentino via e-mail.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2