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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200779
Report Date: 12/06/2023
Date Signed: 12/06/2023 02:30:08 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
10/19/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231019124007
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:
12/06/2023
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Irwyn Legarda, StaffTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff yell at client
Staff do not treat client with dignity or respect
Staff do not ensure client is adequately fed
INVESTIGATION FINDINGS:
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On 12/6/2023 at 12:45PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegations above. LPA met with Staff, Irwyn Legarda and informed him the reason for visit.

During the course of investigation, LPA interviewed 4 clients, 2 staff, and complainant. LPA obtained and reviewed documents including facility sample menu, LIC500, physician's report, IPP, ISP, and emergency information.

Staff yell at client
Staff do not treat client with dignity or respect
Interview with staff indicated that staff speaks loudly to clients due to some clients is hard of hearing. Staff stated they have not yelled at clients or be rude to clients. Interview with C2 revealed that staff are nice and respectful to clients. C2 have not witness staff yell or be rude to clients. (continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
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-20231019124007
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: 12/06/2023
NARRATIVE
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After reviewing C1's ISP (Individual Service Plan), LPA observed that C1 has a history of making up stories that are not true or factual.

Staff do not ensure client is adequately fed
Interview with staff and complainant revealed that C1 buys food instead of eating facility's food. C1's parents have purchased food for C1, but C1 wouldn't eat the food and the food would go bad. Interview with clients indicated that staff makes food for clients. C2 stated that S3 makes foods such as chicken, chicken adobo, sandwich, pizza, and Filipino food. C2 stated that staff provides foods to all clients everyday. LPA observed facility had 2-day of perishable and 7-day nonperishable food supplies available.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2