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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200055
Report Date: 02/15/2024
Date Signed: 02/15/2024 12:39:57 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
09/25/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230925102302
FACILITY NAME:SUMMERFIELD HOMES #1FACILITY NUMBER:
079200055
ADMINISTRATOR:MARGARITA D PAGDANGANANFACILITY TYPE:
735
ADDRESS:5313 SUMMERFIELD DRIVETELEPHONE:
(925) 706-9990
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 6DATE:
02/15/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Margarita Pagdanganan, AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Client sustained unexplained bruises while in care
INVESTIGATION FINDINGS:
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On 02/15/24 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver findings of above allegation. LPA explained the purpose of the visit with ADM.

Allegation: Client sustained unexplained bruises while in care
Finding: Unsubstantiated
During the course of the investigation the Department obtained C1 medical documents from Kaiser Permanente, Antioch from September 2023. Medical records revealed C1 was interviewed by W1, W2, W3, W4, W5, W6. C1 consistently denied any sort of abuse and reiterated through each interview that the bruises were a result of itchy skin. Confirmed bruising occurred in areas where C1 could reach to scratch.

Continued on next page, LIC 9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
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-20230925102302
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: SUMMERFIELD HOMES #1
FACILITY NUMBER: 079200055
VISIT DATE: 02/15/2024
NARRATIVE
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The Department obtained a copy of Antioch Police Report that was closed without further investigation due to C1 denying abuse. W6 stated facility staff provides “immaculate” care to C1 who has been living at the facility since May 2013. W6 also stated she has no concerns for C1’s safety at the facility.

Interview with S1 revealed S1 was in communication with C1 physician when redness rash had appeared on 9/17/2023. S1 noticed the redness began turning into bruising by the following day and provided additional pictures to C1 physician as the “rash” developed on arms and legs. S1 was following all order from C1 physician. S2 stated that C1 is verbal and communicated that the “rash” was itchy. S2 believes it was a side effect from a new medication C1 was on. Since C1 medication was changed the “rash” and bruising has resolved.

Based on records review, interviews conducted, and observations made, the Department has investigated the above allegation that client sustained unexplained bruises while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2