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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601399
Report Date: 06/21/2023
Date Signed: 06/21/2023 10:48:22 AM

Substantiated


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
06/13/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230613164228
FACILITY NAME:ABIGAIL BOARD AND CAREFACILITY NUMBER:
075601399
ADMINISTRATOR:IRVAN, TAMSIEFACILITY TYPE:
740
ADDRESS:4369 ROSE LANETELEPHONE:
(925) 825-3594
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 0DATE:
06/21/2023
UNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:TIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Unlawful eviction
INVESTIGATION FINDINGS:
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On 06/21/2023 starting at 8:42 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to attempt to conduct a complaint investigation for the above allegation. LPA rang the doorbell at 8:55am and again at 9:00 am with no answer. LPA then called Licensee Tamise Irvan.

The Licensee confirmed on the phone that the facility did close on Thursday June 15th 2023 and that they gave notice to the residents and their responsible parties on June 11th 2023 and they would need to be out by June 15th 2023.

Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided via mail.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
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-20230613164228
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: ABIGAIL BOARD AND CARE
FACILITY NUMBER: 075601399
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2023
Section Cited
HSC
1569.682(a)(1)(B)(2)
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Provide each resident or the resident’s responsible person with a written notice no later than 60 days before the intended eviction...

This requirement is not met as evidenced by…
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The Licensee agrees to send a roster of the residents and their new locations by POC date.
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The facility gave a 4 day notice of closure to resident and responsible person which posed an immediate health, safety or personal rights risk to persons in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC9099 (FAS) - (06/04)
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