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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201069
Report Date: 01/08/2025
Date Signed: 01/08/2025 04:07:56 PM

Substantiated


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
12/30/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20241230154440
FACILITY NAME:GENTLE HEART CARE SERVICES INCFACILITY NUMBER:
019201069
ADMINISTRATOR:SPENCER, ALANNAFACILITY TYPE:
735
ADDRESS:1559 D STREETTELEPHONE:
(510) 397-4813
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 6DATE:
01/08/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Alanna Spencer/Administrator TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility's Neighborhood Complaint Policy not followed.
INVESTIGATION FINDINGS:
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On this day, 1/08/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegatiion. LPA met with staff, Sameer Aziz, and informed the reason for visit. LPA spoke over the phone with Alanna Spencer, administrator (ADM), and informed the reason for visit. ADM arrived at 1:15 pm.

During the course of investigation, LPA reviewed residents' files, conducted interiews, and obtained copies of resident's records.

Reporting party (RP) stated he had witnessed the facility resident breaking into his car multiple times. RP further reported that the other neighbors have confessed about having this same individual breaking into their car and being caught.

......continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
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 7
Control Number 15-AS-20241230154440
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: 01/08/2025
NARRATIVE
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RP stated he spoke over the phone with the facility staff and was told call the police. He was told that R1 was told not to leave but R1 escaped through the window.

LPA interviewed the ADM who stated they received a complaint from the neighbor and confirmed she told the neighbor to call the police and that R1 was told not to leave and that R1 escaped through the window. ADM stated she did not take other actions after the complaint was received, therefore the allegation is substantiated. A finding that the allegation is substantiated means that the preponderance standard is met.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction (POC) by plan of correction due date, and any repeat violations within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the ADM. ADM has to leave and authorized Sameer Aziz to sign and receive this report.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20241230154440
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2025
Section Cited
CCR
80022(k)
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80022 Plan of Operation
(k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so

-This requirement is not met as evidenced by: .
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Administrator to do the following and submit proof by 1/22/25:
1. Call and meet with the neighbor to address the complaint.
2. Call for an Interdisciplinary Meeting with the resident's case manager.
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-Based on interviews, the licensee did not comply with the section above by not following the facility's Neighborhood Complaint Policy and not addressing the neighbor's complaint.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
12/30/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20241230154440

FACILITY NAME:GENTLE HEART CARE SERVICES INCFACILITY NUMBER:
019201069
ADMINISTRATOR:SPENCER, ALANNAFACILITY TYPE:
735
ADDRESS:1559 D STREETTELEPHONE:
(510) 397-4813
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 6DATE:
01/08/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Alanna Spencer/Administrator TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff are not providing adequate supervision to a resident (R1) in care.
INVESTIGATION FINDINGS:
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On this day, 1/08/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegatiion. LPA met with staff, Sameer Aziz, and informed the reason for visit. LPA spoke over the phone with Alanna Spencer, administrator (ADM), and informed the reason for visit. ADM arrived at 1:15 pm.

During the course of investigation, LPA reviewed resident's files, conducted interiews, and obtained copies of resident's records including but not limited to LIC602 Physician's Report, Individual Program Plan (IPP) and LC625 Appraisal/Needs and Services Plan.

Reporting party (RP) stated he had witnessed the facility resident breaking into his car multiple times. RP further reported that the other neighbors have confessed about having this same individual breaking into their car and being caught, was physically attacked and R1 unsupervised.
......continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20241230154440
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: 01/08/2025
NARRATIVE
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LPA interviewed the ADM and staff (S1 and S2), and reviewed R1's file.

The ADM and S1 stated that the neighbor came to the facility and complained about the incidents. The ADM, S1 and S2 stated R1 can leave the facility unassisted which LPA confirmed upon review of R1's LIC602 Physician's Report.

Based on information gathered, the allegation of 'Staff are not providing adequate supervision to a to a resident (R1) 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 deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7