019201069-3-9-2023-15-AS-KHOS-CQJLKR-20230403084957

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201069
Report Date: 03/09/2023
Date Signed: 03/09/2023 06:33:01 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
03/02/2023 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20230302160451

FACILITY NAME:	GENTLE HEART CARE SERVICES INC		FACILITY NUMBER:	019201069
ADMINISTRATOR:	SPENCER, ALANNA		FACILITY TYPE:	735
ADDRESS:	1559 D STREET		TELEPHONE:	(510) 397-4813
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	6	CENSUS: 4	DATE:	03/09/2023
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Alanna Spencer/Administrator		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Facility staff assaulted client (C1) in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with staff, Sameer Aziz. and informed the reason for visit. Alanna Spencer, administrator, arrived after about 35 minutes.

During the course of investigation, LPA obtained copies and reviewed client (C1) records including but not limited to Physician's Report, Behavioral Health Care Services, Referral Assessment, Risk Asessment, LIC601 Identification and Emergeny Contact Information, Unusual Incident Reports. LPA interviewed staff (S1 and S2), administrator and clients (C1, C2 and C3).

C1 stated the incident happened when C1 asked S1 for C1's PRN medication to calm C1 down but staff (S1) gave C1 a different medication. When C1 asked for the key to the medication cabinet, S1 pushed and assaulted C1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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-20230302160451

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: GENTLE HEART CARE SERVICES INC	FACILITY NUMBER: 019201069
	VISIT DATE: 03/09/2023

NARRATIVE

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On this same day, 3/09/23, S1 was interviewed who stated C1 was already having a bad day when C1 came home from day program, and asked for medication, not the medication indicated by C1 during interview and the said medication is not a PRN. S1 stated C1 tried to force open the medication cabinet, and when S1 tried prevent C1 from taking medications out by standing in between the medication cabinet and C1, C1 assaulted S1.

Client C2 stated being at the facility but does not remember what transpired. C3 also was at the facility when the incident happened, and stated C1 started the incident. C2 and C3 stated staff are treating them good.

The administrator stated she was not at the facility when the incident started, and S1 called her. The administrator indicated when she arrived to the facility, she has to literally put herself in between C1 and S1 as C1 continued to assault S1. Police was called. Staff S2 stated S1 is a good staff, and never been physical to any of the clients.

Based on the information gathered. the allegation of facility staff assaulted client in care.is closed as unsubstantiated. A finding that the complaint is unsubstantiated means 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 citation issued,

Exit interview conducted, and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

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