075601544-10-19-2020-15-AS-KHOS-BW4KJM-20201208065657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601544
Report Date: 10/19/2020
Date Signed: 10/19/2020 03:10:00 PM

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
04/14/2020 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20200414154313

FACILITY NAME:	IMMACULATE HOME AT WITHERS		FACILITY NUMBER:	075601544
ADMINISTRATOR:	CABATINGAN, GEORGINA G.		FACILITY TYPE:	740
ADDRESS:	3151 WITHERS AVENUE		TELEPHONE:	(925) 274-1527
CITY:	LAFAYETTE	STATE: CA	ZIP CODE:	94549
CAPACITY:	6	CENSUS: 6	DATE:	10/19/2020
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Norberto Geronimo, Administrator		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was raped by a staff member at the facility
Staff member yelled at resident
Staff member threatened resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On this day, October 19, 2020 at 2:30 PM, Licensing Program Analyst (LPA) D Panlilio conducted a Face-time tele-visit with Administrator to deliver the findings of above allegations. LPA explained the reason for the tele-visit and discussed with Administrator the deliverance of this complaint. Due to the shelter in place order by the Governor effective March 17, 2020, Administrator was not physically available to sign this report.

Allegation: Resident was raped by a staff member at the facility
Investigation Finding: UNSUBSTANTIATED
During the course of the investigation, R1 made inconsistent statements regarding being physically abused by staff. R1 was unable to provide details regarding the incident(s). In statements made to police and investigator, R1 could not provide any significant details to corroborate her allegation.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rajind Basi	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020

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-20200414154313

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: IMMACULATE HOME AT WITHERS	FACILITY NUMBER: 075601544
	VISIT DATE: 10/19/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Per witnesses, R1 was angry about being placed in the facility because she wanted to be home. R1 never made any allegation of physical abuse while she was living at the facility. Facility staff made no disclosures of any inappropriate behavior and denied the allegation. Other residents were interviewed and had provided no relevant information.

This department has investigated the complaint alleging that resident was raped by staff member at the facility. We have found that the complaint is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff member yelled at resident
Investigation Finding: UNSUBSTANTIATED
No neutral witnesses were identified that corroborated the allegation that staff member yelled at resident; furthermore, information obtained from witnesses on behalf of the subject resident was insufficient to to corroborate the allegation. Facility staff were interviewed and denied having yelled, or having knowledge of staff yelling at or threatening residents.

This department has investigated the complaint alleging that staff member yelled at resident. We have found that the complaint is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff member threatened resident
Investigation Finding: UNSUBSTANTIATED
Witness information obtained was insufficient to establish that any staff member had yelled at or threatened any resident.

Based on the Department’s investigation, the allegation that staff member threatened resident is unsubstantiated, meaning that 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.

Exit interview conducted and a copy of report provided to Administrator via e-mail.

SUPERVISOR'S NAME: Rajind Basi	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2