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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200750
Report Date: 12/09/2020
Date Signed: 12/09/2020 04:41:44 PM



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
07/23/2019 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20190723130812
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: 30DATE:
12/09/2020
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Jonabelle Tolentino/AdministratorTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Licensee failed to notify resident's authorized representative of resident's hospitalization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo called and spoke with Jonabelle Tolentino, administrator, to deliver the findings on the above allegation. LPA explained that due to Shelter in Place Order and directive by management to telework, the deliverance is done via video conference.

It was alleged that the resident’s responsible person was not notified when R1 was hospitalized as a result of hitting another resident.

During the course of investigation, LPA reviewed R1’s file and obtained copies of documents. LPA interviewed Jonabelle Tolentino, administrator, who indicated she did not notify R1’s responsible person of R1’s hospitalization.

.....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
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 5
Control Number 15-AS-20190723130812
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: 12/09/2020
NARRATIVE
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Based on information obtained, the preponderance of evidence standard has been met, therefore the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations (see LIC 9099D). Failure to submit proof of correction by plan of correction due date along with the LIC9098 Proof of Correction form and any repeat violation within 12-month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Ms. Tolentino.

Exit interview conducted. Appeal Rights, LIC9098 and copy of this report provided via e-mail.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20190723130812
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: 12/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2020
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have....personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services........
This requirement is not met as evidenced by:
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Administrator to do the following:
1. Read and understand the Regulation to ensure compliance.
2. In-service staff.
Proof to be submitted by 12/23/2020.
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-Based on interview and records review, the licensee did not comply with the Regulation by failing to notify the responsible person of R1’s hospitalization which poses potential personal rights risk to resident in care.
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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: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
LIC9099 (FAS) - (06/04)
Page: 3 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
07/23/2019 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20190723130812

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: DATE:
12/09/2020
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Jonabelle Tolentino/AdministratorTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Resident was served a 30 day eviction notice without justification.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo called and spoke with Jonabelle Tolentino, administrator, to deliver the finding on the above allegation. LPA explained that due to Shelter in Place Order and directive by management to telework, the deliverance is done via video conference.

It was alleged that resident was served a 30-day eviction without justification. During the course of investigation, LPA reviewed R1’s file and obtained copies of documents. LPA interviewed staff (S1) and Jonabelle Tolentino. S1 stated and confirmed a 30-day eviction was served to R1. A copy of the eviction was sent by the facility’s attorney to R1’s responsible person. R1 had two incidents hitting other residents. The last incident resulted to R1 being sent out to hospital. Both S1 and administrator stated R1 was assessed and documents obtained confirmed their statements.

...........continued on 9099C
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: 12/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20190723130812
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: 12/09/2020
NARRATIVE
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Due to change in behavior, R1 is no longer appropriate to return to the facility, therefore, the 30-day eviction is justified, and the allegation is deemed unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

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

DATE: 12/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5