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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200766
Report Date: 03/12/2022
Date Signed: 03/12/2022 11:52:16 AM

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
03/16/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20210316104710
FACILITY NAME:QUEEN CARE HOMEFACILITY NUMBER:
019200766
ADMINISTRATOR:PITSCHNER, MARIANFACILITY TYPE:
735
ADDRESS:22090 QUEEN STREETTELEPHONE:
(510) 584-6922
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:6CENSUS: 6DATE:
03/12/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Marian Pitschner, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff member is behaving aggressively towards clients.
INVESTIGATION FINDINGS:
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On 3/12/2022, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a complaint investigation regarding the allegations above. LPA met with Administrator, Marian Pitschner and informed her about the allegations.

During the investigation, C7 had multiple special incident report for aggressive behavior, staff followed individual program plan on how to address aggressive behavior by talking calmly to C7 and re-direct him by walking outside the house, watch TV or taking him to stores around the neighborhood and etc.

LPA has no way of verifying the allegation staff member is behaving aggressively towards clients, C7 moved out and cannot be interviewed to verify allegation. Therefore, this allegation is unsubstantiated. LPA tried to interview client’s in care, one of the clients is showing anxiety behavior and could not be interviewed, other clients went out for lunch with 4 staff.
... continued to LIC9099C...


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2022
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 2
Control Number 15-AS-20210316104710
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: QUEEN CARE HOME
FACILITY NUMBER: 019200766
VISIT DATE: 03/12/2022
NARRATIVE
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Based on records review and interviews conducted, the above allegation is unsubstantiated. A finding that the complaint is unsubstantiated meaning 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. Copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2