075601508-2-28-2022-15-AS-KHOS-CKBPNU-20221018112830

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601508
Report Date: 02/28/2022
Date Signed: 02/28/2022 06:21:43 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
02/28/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220228103054

FACILITY NAME:	CORTONA PARK		FACILITY NUMBER:	075601508
ADMINISTRATOR:	AGUSTIN SAMANIEGO		FACILITY TYPE:	740
ADDRESS:	150 CORTONA WAY		TELEPHONE:	(925) 240-0733
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	150	CENSUS: 106	DATE:	02/28/2022
		UNANNOUNCED	TIME BEGAN:	05:37 PM
MET WITH:	Sharon Monck, Executive Director		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Facility is understaffed to provide care and supervision

INVESTIGATION FINDINGS:

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On 2/28/2022, Licensing Program Analyst (LPA) L. Ibo conducted an unannounced complaint visit, LPA explained the purpose of the visit with administrator Sharon Monck.

During the course of investigation, the Department obtained copies of resident roster, staff schedule, a copy of corrective action and staff roster.

LPA conducted interview and records review, facility did have staff available for all shift ( AM, PM and Night shift), staff also volunteered to work overtime to cover shifts if someone called and sick.

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 to Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

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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