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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200120
Report Date: 08/24/2023
Date Signed: 08/24/2023 03:50:03 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
08/14/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230814122853
FACILITY NAME:SUMMERFIELD HOMES IVFACILITY NUMBER:
079200120
ADMINISTRATOR:CERILO WILLIAM A BELENFACILITY TYPE:
735
ADDRESS:5415 CHEROKEE WAYTELEPHONE:
(925) 470-3888
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 5DATE:
08/24/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Chris De Vera, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff pulled client's hair
Facility staff cursed at client
INVESTIGATION FINDINGS:
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On 08/24/23 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, gathered information and delivered investigation findings to administrator (ADM). LPA explained the purpose of the visit with ADM.

Allegation: Staff pulled client's hair
Finding: Unsubstantiated
During investigation, LPA interviewed 3 staff (ADM, S1, S2) who denied pulling any clients' hair or physically abusing them. LPA also interviewed 3 clients (C2, C3, C4) who stated that staff treat them well and do not abuse them physically or verbally. 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: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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-20230814122853
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 IV
FACILITY NUMBER: 079200120
VISIT DATE: 08/24/2023
NARRATIVE
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 On 08/09/23, S1 confirmed with LPA that it was her and not S2 that gave C1 a shower that morning. S1 stated S2 was not inside C1's bedroom. S1 stated C1 had an argument with C2 and C3 at the breakfast table. S2 stated she told the clients (C1, C2, C3, C4) not to argue and redirected them. C1 felt that S2 sided with the other clients and kept scowling at S2 all morning. Staff (ADM, S1, S2) denied pulling C1's hair. ADM stated C1 has a history of making false accusations, yelling, cursing and screaming at staff and clients she does not like.

Based on interviews and record reviews which were conducted, although the allegation may have happened and/or is valid, there is not a preponderance of evidence, to prove the allegation that staff pulled client's hair did or did not occur. Therefore, the allegation is unsubstantiated.

Allegation:Facility staff cursed at client
Finding: Unsubstantiated
During investigation, Clients (C2, C3, C4) confirmed with LPA that staff never cursed, scream or yell at them. ADM stated C1 has a history of making false accusations about staff or clients she does not like. ADM stated he has witnessed C1 scream, curse, yell and make rude gestures at others on several occasions and make false accusations about others. Staff denied cursing any client at the facility.

Based on interviews and record reviews which were conducted, although the allegation may have happened and/or is valid, there is not a preponderance of evidence, to prove the allegation that staff cursed at client did or did not occur. Therefore, the allegation is unsubstantiated.

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

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2