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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201136
Report Date: 12/14/2022
Date Signed: 12/14/2022 05:09:04 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
07/18/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220718091949
FACILITY NAME:PACALDO-YEEFACILITY NUMBER:
019201136
ADMINISTRATOR:PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:999 TORRANO AVETELEPHONE:
(650) 393-0265
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:14CENSUS: 11DATE:
12/14/2022
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Kester Orendain, Care StaffTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not provide assistance to resident(s) in a timely manner.
Staff unable to meet residents needs due to language barrier.
Facility does not provide nutritious meals.
Facility food menu is not posted.
INVESTIGATION FINDINGS:
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On 12/14/2022 at 2:35 PM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a subsequent complaint investigation in regard to the above allegations. LPA met with care staff and spoke with the Administrator Tess Yee on the phone. LPA informed the purpose of the visit. Administrator authorized care staff to sign on the report.

Allegation: Staff did not provide assistance to resident(s) in a timely manner – Unsubstantiated
The Department has investigated this allegation and per records review and interviews found most residents received assistance in a timely manner. 9 residents were interview, 7 of them have no complaint about receiving care and supervisor, 1 resident stated that staff didn't come when the bell was rang sometimes but couldn’t remember when it was. Another resident was confused.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
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-20220718091949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PACALDO-YEE
FACILITY NUMBER: 019201136
VISIT DATE: 12/14/2022
NARRATIVE
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Allegation: Staff unable to meet residents needs due to language barrier – Unsubstantiated
The Department has investigated this allegation and per records review and interviews found that no staff was identified of speaking no English. Residents stated that staff speak English and could communicate with them.

Allegation: Facility does not provide nutritious meals – Unsubstantiated
The Department has investigated this allegation and per records review and interviews found that beef sandwiches, soup, chopped lettuces, and grapes was observed for lunch during visit on 7/21/22; Staff was preparing fresh chicken and cheese sandwiches, macaroni, broccolis, and grapes for dinner during visit on 12/14/22. 7 residents have no complaint about food.

Allegation: Facility food menu is not posted – Unsubstantiated
The Department has investigated this allegation and per records review and interviews found that menus posted on the wall in the hallway and inside the kitchen was observed during multiple visits.

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

Exit interview conducted with the care staff and Administrator on the phone, and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2