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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201133
Report Date: 09/19/2024
Date Signed: 01/10/2025 03:20:05 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
09/10/2024 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20240910135724
FACILITY NAME:NORTH STAR RESIDENTIAL HOMEFACILITY NUMBER:
019201133
ADMINISTRATOR:ONWURAH, ANNETTEFACILITY TYPE:
735
ADDRESS:1429 57TH AVETELEPHONE:
(510) 260-9865
CITY:OAKLANDSTATE: CAZIP CODE:
94621
CAPACITY:6CENSUS: 3DATE:
09/19/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Annette Onwurah, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff mistreated resident.
INVESTIGATION FINDINGS:
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On 1/10/25 at 1:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an amended complaint investigation and deliver findings in regard to the allegation above. LPA met with Annette Onwurah, Administrator and explained the purpose of the visit.

During the course of the investigation LPA interviewed facility residents (R2, R3 and R4) and facility staff (S1, S2 and S3).

In September of 2024 R1 alleged that she was being mistreated by staff by them not allowing her to cook. At the time of the initial visit R1 refused to be interviewed by LPA. LPA called R1 several times but each time she refused to talk to LPA. R1 no longer lives at the facility and there is no currrent contact information for her.

***report continues on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
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-20240910135724
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: NORTH STAR RESIDENTIAL HOME
FACILITY NUMBER: 019201133
VISIT DATE: 09/19/2024
NARRATIVE
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***report continues from LIC9099***

LPA interviewed the residents currently residing at the facility. R4 is the only resident who lived at the facility at the same time as R1. R4 remembered R1 but couldn't provide any details as to her treatment at the facility. R4 stated that he enjoys living at the facility and that the staff treat him "very well." R4 also stated that he has never seen staff mistreat him or the other residents. R2 and R3 also stated that they feel safe at the facility and that the staff take good care of them. Both R2 and R3 stated that have never seen staff at the facility mistreat the residents.

LPA also interviewed staff currently working at the facility. S1 remembers the issues they had with R1 wanting to use the gas stove. S1 felt it was very dangerous situation as R1 had little safety awareness around the stove and refused to let staff help. S1 alerted R1's care team about the situation and documented it in R1's care notes. S1 stated that she feels that R1's rights were never violated and that R1 was never mistreated.

Both S2 and S3 remember the issues they had with R1 wanting to use the gas stove. Both S2 and S3 feel that staff were only trying protect R1 from injury and that she was never mistreated. Both S2 and S3 both stated that they have never seen other staff mistreat the residents.

This agency has investigated the complaint alleging staff mistreated resident. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2