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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200779
Report Date: 07/28/2022
Date Signed: 07/28/2022 02:28:52 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
05/26/2020 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20200526163646
FACILITY NAME:ANDALUCIA HOMEFACILITY NUMBER:
019200779
ADMINISTRATOR:LEGARDA, MARISSAFACILITY TYPE:
735
ADDRESS:1083 ANDALUCIA STREETTELEPHONE:
(650) 892-9264
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:4CENSUS: 4DATE:
07/28/2022
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Jet Legarda, Staff TIME COMPLETED:
02:43 PM
ALLEGATION(S):
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Staff verbally abused resident.
Facility staff hit resident
INVESTIGATION FINDINGS:
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On 7/28/2022 at 2:10 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger H. Humpal arrived unannounced to conduct a complaint investigation and deliver findings in regard to the allegations above. LPA met with staff Jet Legarda.

During the course of investigation, LPAs interviewed 4 clients and 3 staff. LPA also obtained and reviewed 3 client files including: physician’s report, care plan, and emergency information.

Staff hits the resident.
Interviews with clients revealed that clients did not observed any incidents were staff hit a client. Interview with staff indicated that they have not witnessed any staff hitting a client.

Continued on 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
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-20200526163646
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: ANDALUCIA HOME
FACILITY NUMBER: 019200779
VISIT DATE: 07/28/2022
NARRATIVE
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Staff yells at the resident.
Interview with clients revealed that staff does not yell at clients. Interview with staff indicated that they have not witnessed any staff yelling at clients.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2