071440014-3-9-2022-15-AS-KHOS-CCRRW2-20220322132224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 071440014
Report Date: 03/09/2022
Date Signed: 03/09/2022 01:34:57 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
03/01/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220301162236

FACILITY NAME:	CONCORD HOUSE - SATELLITE I		FACILITY NUMBER:	071440014
ADMINISTRATOR:	LEYBA, SIS. MARY ANN		FACILITY TYPE:	735
ADDRESS:	2057 BONIFACIO STREET		TELEPHONE:	(925) 825-9757
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	3	CENSUS: 3	DATE:	03/09/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Mary Ann Leyba, Administrator		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Staff handled client in a rough manner

INVESTIGATION FINDINGS:

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On 3/9/2022, Licensing Program Analyst (LPA) L. Ibo conducted an unannounced complaint visit to conduct an investigation on the above allegation, LPA met with Mary Ann Leyba, Administrator and explained the purpose of the visit.

During the course of investigation, the Department obtained copies of resident roster and staff roster.
LPA conducted interviews. Based on interview conducted, C1 denied getting hurt from staff during a fall incident outside the facility, C1 stated that she like the staff and like living at the facility.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.
No deficiencies cited.

Exit Interview conducted and a copy of this report provided to Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

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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