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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201136
Report Date: 02/25/2025
Date Signed: 02/25/2025 03:07:19 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
02/21/2025 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20250221091643
FACILITY NAME:PACALDO-YEEFACILITY NUMBER:
019201136
ADMINISTRATOR:PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:999 TORRANO AVETELEPHONE:
(650) 393-0265
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY:14CENSUS: 13DATE:
02/25/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Digna Ramos, Administrator TIME COMPLETED:
03:20 PM
ALLEGATION(S):
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9
Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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On 2/25/2025 at 11:00am, Licensing Program Analyst (LPA), K. Nguyen arrived unannounced to conduct investigation for the above allegation. LPA met with Digna Ramos, Administrator (ADM), and explained the reason for the visit.

Allegation: Staff did not safeguard resident's personal belongings. - Unsubstantiated

During the investigation LPA toured facility including but not limited to resident rooms, bathrooms, and living/dining area. LPA conducted staffs interviewed, and residents interviewed. LPA reviewed resident records including but not limited to residents: Admission agreement, Preplacement Appraisal, Physician report, need and services plan, and Theft and Loss Program policy (Resident property and Valuables).

Report continued on LIC 9099c...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
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 2
Control Number 15-AS-20250221091643
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: PACALDO-YEE
FACILITY NUMBER: 019201136
VISIT DATE: 02/25/2025
NARRATIVE
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LPA interviewed 5 residents 2 out of 3 are nonverbal. R7, R9, and R11 stated that they did not have any missing items, nor misplace of any of their personal belonging. R1, and R6 was nonverbal but can communicate with signs. R1 show thumbs up when asked if all the clothing belongs to R1. R1 was able to shake R1 heads indicated that it was R1 clothing and belonging that is in R1 closet. R1 put thumb down when asked if R1 wore things that does not belong to R1. LPA observed residents have their own separated closet / dresser. LPA conducted staff’s interview. 4 out of 4 stated that they have not witness or heard any residents’ complaints about their personal belonging are missing.

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 and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2