071440106-8-18-2022-15-AS-KHOS-CHMKUV-20220825081322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 071440106
Report Date: 08/18/2022
Date Signed: 08/18/2022 02:46:29 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
08/16/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220816084328

FACILITY NAME:	CONCORD HOUSE		FACILITY NUMBER:	071440106
ADMINISTRATOR:	LEYBA, MARY ANN		FACILITY TYPE:	735
ADDRESS:	2301 MT. DIABLO ST.		TELEPHONE:	(925) 825-4423
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	16	CENSUS: 13	DATE:	08/18/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Mary Ann Leyba, Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility staff filled out resident’s voting ballot without resident’s knowledge

INVESTIGATION FINDINGS:

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On 08/18/22 at 1:30PM, Licensing Program Analyst (LPA) conducted an unannounced complaint visit, met with administrator, gathered information, interviewed clients (C2, C3 & C4) and staff (Administrator, S1). LPA explained the purpose of the visit and delivered the investigation findings.

Allegation: Facility staff filled out resident’s voting ballot without resident’s knowledge
Investigation Finding: Unsubstantiated
Based on interviews and record reviews which were conducted, clients receive their voting ballots by mail at the facility. C2, C3 and C4 confirmed with LPA that staff do not interfere with their choices on the ballot and do not fill them out. Clients stated that they make their own choices and complete the ballots by themselves. Staff denied filling out the voter ballots for clients.

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 via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

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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