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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200750
Report Date: 06/05/2024
Date Signed: 06/05/2024 02:15:37 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
05/31/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20240531102146
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:
06/05/2024
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Jonabelle Tolentino, Administrator TIME COMPLETED:
02:35 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staff not affording resident the personal right to leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 On 6/5/2024 at 1:05 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Administrator Jonabelle Tolentino.

On the allegation of Staff not affording resident the personal right to leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. Based on record review and interviews the facility has a delayed egress door and alarms that go off when residents with dementia attempt to leave the facility. S1 states that if a residents does not have a diagnosis of Dementia they are able to come and go as they please. R1 does have a diagnosis of Dementia and documentation stating that R1 can not leave the facility unassisted

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
Exit interview conducted and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
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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