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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200750
Report Date: 05/10/2024
Date Signed: 05/10/2024 07:51:50 PM

Substantiated


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
08/15/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230815095918
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:
03:50 PM
MET WITH:Jonabelle Tolentino/Administrator TIME COMPLETED:
08:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff yelled at resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with Jonabelle Tolentino, administrator, and informed the reason for visit.

During the course of investigation, LPA obtained copies of staff schedule, LIC9020 Register of Facility Residents, reviewed and obtained copies of residents' records. LPA reviewed facility video footage with the administrator and interviewed 5 residents on 8/17/23 and staff on 8/17/23, 8/18/23 and on this day, 5/10/24.

It was alleged that on 8/2023, when R1 questioned S1 when S1 took out R1's personal belongings from R1's drawers in his bedroom to clean and in the process S1 threw out some of R1's personal belongings, S1 yelled at R1.
.....continued on 9099C(page 2)
Substantiated
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)
Page: 1 of 5
Control Number 15-AS-20230815095918
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: 05/10/2024
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
R1 was interviewed and stated when he was at the dining room on 8/12/23 and asked S3 if S3 has seen his salt and salad dressing in his room, S1 yelled at him. One of the other 4 residents interviewed stated she was yelled at by S1. .

Four staff including S1 and S3 were interviewed. Three of the staff denied yelling any residents including R1. One of these staff stated she must be in the laundry room when the incident in the dining room happened. The other staff stated not observing the incident but have observed S1 raising voice on other residents including R1. Although S1 denied yelling at R1, video camera footage of the alleged day of incident was reviewed by LPA and administrator and observed R1 talking to S3 and S1 came to the scene. S1 was observed pointing fingers and moving her hands while talking to R1. Hand movements and facial expressions seemed S1 raising voice which administrator agreed.

Based on information gathered, the preponderance of evidence standard has been met, therefore, the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations. and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/15/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230815095918

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:
03:50 PM
MET WITH:Jonabelle Tolentino/Administrator TIME COMPLETED:
08:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with Jonabelle Tolentino, administrator, and informed the reason for visit.

During the course of investigation. LPA obtained copies of staff schedule, LIC9020 Register of Facility Residents, reviewed and obtained copies of residents' records. LPA conducted inspection on 817/23 and interviewed residents on 8/17/23 and staff on 8/17/23, 8/18/23 and on this day, 5/10/24.

R1 stated that on 8/2023, S1 took all of R1's personal belongings out of the drawers in R1's bedroom to clean and in the process S1 threw out some of R1's personal belongings and food items.

....continued on 9099C
Unsubstantiated
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)
Page: 3 of 5
Control Number 15-AS-20230815095918
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: 05/10/2024
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
Four staff who were present on the day of the alleged incident were interviewed. Two of the staff denied throwing any of the residents personal belongings. The other 2 staff who did the cleaning stated they threw away only the food items that were expired, rotten and with mold and told R1 they are throwing them away.

Four other residents were interviewed including R1's roommate. R1's roommate confirmed that the 2 staff who did the cleaning of their room only threw away the food items that were expired, rotten and with mold and the items that were not expired were not thrown away. LPA observed some food items in the room when LPA conducted inspection on 8/17/23. The other 3 residents stated that none of their personal belongings were thrown away.

Based on information gathered, the allegation is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided to the administrator.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230815095918
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
HSC
1569.269(a)(1)
1
2
3
4
5
6
7
ยง1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
-This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator to in-service the staff and submit copy of training topic with attendees signatures by 5/24/24.
8
9
10
11
12
13
14
-Based on interviews and review of video footage, the licensee did not comply with the section above when staff yelled at resident which posed a potential personal rights risk to person in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5