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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200750
Report Date: 05/10/2024
Date Signed: 05/10/2024 12:02:23 PM

Unfounded


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
05/09/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240509141643
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: 33DATE:
05/10/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:TIME COMPLETED:
11:55 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff failed to safeguard resident's (R1) personal belonging.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Delmundo arrived unaanounced to investigate the above allegation. LPA met with Jonabelle Tolentino, administrator, and informed the reason for visit.

It was alleged that resident's (R1) roommate was wearing R1's jewelry and does not know if the jewelry was stolen or a coincidence that the roommate has it.

LPA interviewed R1 who stated the roommate was R1's roommate in the previous private residence where R1 left the jewelries. Based on information provided by R1 that the jewelries and roommate are not in the facility, which the Department does not have jurisdiction, the allegation is closed as unfounded. An unfounded finding means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No deficiency cited. Exit interviewed conducted, and copy fof this report provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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