019200750-2-1-2023-15-AS-KHOS-CP4LE2-20230216074050

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200750
Report Date: 02/01/2023
Date Signed: 02/01/2023 03:31:00 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
01/25/2023 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20230125080856

FACILITY NAME:	SCOTT VILLA		FACILITY NUMBER:	019200750
ADMINISTRATOR:	JONABELLE TOLENTINO		FACILITY TYPE:	740
ADDRESS:	1560 MIDDLE LANE		TELEPHONE:	(510) 782-7833
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	35	CENSUS: 35	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Jonabelle Tolentino/Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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-Staff did not properly safeguard resident's cash resources.

-Staff did not properly safeguard resident's personal property.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unaanounced to investigate the above allegations. LPA met with Jonabelle Tolentino, administrator, and informed the purpose of visit.

LPA obtained copies of December 2022, January 2023 and current rosters. From the rosters, LPA selected 2 residents for review of records. LPA interviewed the administrator, staff (S1, S2 and S3) and residents (R1 and R2) and resident's family member (FM). LPA also obtained copies of residents' following documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report' Admission Agreement' Pre-placement Appraisal; LIC625 Appraisal/Needs and Services Plan; LIC621 Client/Resident Personal Property and Valuables

.......continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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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Control Number 15-AS-20230125080856

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: 02/01/2023

NARRATIVE

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The administrator stated she was not at the facility when R1 moved-in on January 14, 2023. S1, S2 and S3 stated R1 does not have other personal property aside from clothes and footwear when R1 moved-in. The administrator, S1 and S2 stated the facility does not handle residents' cash resources. Review of records showed R1's LIC621 Client/Resident Personal Property and Valuables with no information.

R1 stated she moved-in long time ago and theft has been going on for long time but was not able provide name of the person who's been stealing. LPA interviewed R2 who stated he has not lost anything since he moved-in.

Resident's family member (FM) indicated R1 brought cash and personal property when R1 was brought to the hospital. The hospital may still have R1's cash and personal property which may have not been properly documented when R1 moved out of the hospital. R1 moved to other facility prior to moving to Scott Villa.

Based on the information obtained, there's not a preponderance of evidence to prove that the alleged violations occurred. Therefore, the allegations of 'Staff did not properly safeguard resident's cash resources.', and 'Staff did not properly safeguard resident's personal property.' are closed as unsubstantiated.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

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