075600757-7-30-2025-15-AS-KHOS-DK4MB7-20250731092729

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075600757
Report Date: 07/30/2025
Date Signed: 07/30/2025 03:43:39 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
07/28/2025 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20250728094001

FACILITY NAME:	FAMILY COURTYARD		FACILITY NUMBER:	075600757
ADMINISTRATOR:	TEJERO, NORMA		FACILITY TYPE:	740
ADDRESS:	2840 SALESIAN AVENUE		TELEPHONE:	(510) 235-8284
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94804
CAPACITY:	70	CENSUS: 44	DATE:	07/30/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Norma Tejero, Administarrttro		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff did not accept resident back following hospitalization.

INVESTIGATION FINDINGS:

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On 07/30/2025 around 09:00 AM Licensing Program Analyst (LPA) L. Holmes conducted a 10-day complaint visit. LPA presented the allegations to Joshua Taburaza, Lenie Ibe, and Norma Tejero the Administrator.

During the course of investigation, LPA interviewed three (3) Staff (S1, S2, S3) and three (3) Witnesses (W1, W2, W3). LPA obtained an email chain regarding R1’s placement status, reviewed R1’s file including but not limited to the physician's report, after-visit summaries, psychiatric Emergency Room Services (PES) Intake Evaluation, Medication List and R1’s 30 day written notice to terminate his/her admission agreement.

...continued from LIC9099.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025

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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Control Number 15-AS-20250728094001

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: FAMILY COURTYARD	FACILITY NUMBER: 075600757
	VISIT DATE: 07/30/2025

NARRATIVE

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...continued from LIC9099.

On 07/24/25, R1 was placed on a 51/50 hold at Psychiatric Emergency Services (PES) of Contra Costa Regional Medical Center in Martinez, California due to destruction of property, yelling, screaming, and hitting. Prior to R1’s admission on 04/22/25, W1 verbally agreed with S1 and S2 to assist with relocating R1 if he/she became a threat to the facility due to the nature of R1’s psychiatric background; LPA confirmed the information stated by W1. W1, W2 and W3 recommended additional treatment and has confirmed that R1 has been transferred to in-patient psychiatric services with a 1:1 at Contra Costa Regional Medical Center. W1 also oversees the finances for R1 and has provided the facility with R1’s 30-day written notice to terminate his/her admission agreement with the goal of seeking an Institute for Mental Diseases along with obtaining conservatorship for R1.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED.

Exit interview conducted, and copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025

LIC9099 (FAS) - (06/04)

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