075600757-9-6-2023-15-AS-BFOG-CZU5RR-20240125191134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075600757
Report Date: 09/06/2023
Date Signed: 09/06/2023 11:16:31 AM

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
08/31/2023 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20230831141857

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: 42	DATE:	09/06/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Tejero, Norma Adminstrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility withheld resident's allowance.

INVESTIGATION FINDINGS:

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On this day, 9. 6. 2023 at 9:15AM Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to investigate the above allegations. LPA was greeted by Jiena Guiem, Med-Tech. Around 9:30am administrator Tejero Norma arrived at the facility. LPA explained the purpose of today visit.

Allegation: Facility withheld resident's allowance.

During the course of investigation LPA interviews 2 staff and R1 Payee from Behavior Health County. LPA obtained residents roster and reviewed R1 safeguarded cash resources records. S2 states that the facility did not withhold any resident’s money and have recorded all the cash resources that got handed to residents that were asked by their case manager with residents’ signature upon receiving.

Report continue on LIC 9099...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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-20230831141857

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: 09/06/2023

NARRATIVE

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LPA spoke with R1 payee and confirmed that the facility did not withhold R1 money and is mistaking during the time that R1 got hospitalize. LPA reviewed the cash resources shows that the last amount that R1 have at the facility have been picked up my R1 payee with R1 payee signature dated 6/23/23; therefore, facility did not withhold R1 money.

Based on the information gathered, there was not a substantial amount of evidence to prove that facility withheld resident's allowance. 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC9099 (FAS) - (06/04)

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