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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601437
Report Date: 07/19/2024
Date Signed: 07/19/2024 05:00:56 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
07/17/2024 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240717164255
FACILITY NAME:AN OAK GROVE MANORFACILITY NUMBER:
075601437
ADMINISTRATOR:VELARDE-BAENS, SHIRLEY A.FACILITY TYPE:
740
ADDRESS:2801 OAK GROVE ROADTELEPHONE:
(925) 926-0405
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 4DATE:
07/19/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Licensee Charry Velarde-BaensTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Wrongful eviction.
Staff are inappropriately restraining resident in care.
INVESTIGATION FINDINGS:
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On 07/19/2024 at approximately 03:15 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct the complaint investigation. Upon entry, the LPA informed Licensee Charry Velarde-Baens of the purpose of the visit.

The complaint alleges that Resident R1 was wrongfully evicted.
The LPA reviewed R1's records and interviewed the Licensee. R1 was not evicted.

The complaint alleges that staff inappropriately restrained Resident R2.
The LPA reviewed the pictures from the RP and interviewed Staff S1 and the Licensee. R2 was not restrained.

(Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20240717164255
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AN OAK GROVE MANOR
FACILITY NUMBER: 075601437
VISIT DATE: 07/19/2024
NARRATIVE
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(...Continued from LIC9099)

Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2