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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200150
Report Date: 08/05/2022
Date Signed: 08/15/2022 02:06:33 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
05/03/2022 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20220503133022
FACILITY NAME:APPLETREE ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
079200150
ADMINISTRATOR:NOLITA DAVIDFACILITY TYPE:
735
ADDRESS:2908 SARGENT AVE.TELEPHONE:
(510) 262-0270
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:4CENSUS: 3DATE:
08/05/2022
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Nolita David, AdministratorTIME COMPLETED:
01:36 PM
ALLEGATION(S):
1
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9
Staff hit resident.
Facility does not maintain adequate food supply at facility.
INVESTIGATION FINDINGS:
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13
On 8/5/2022 at 12:15 pm, Licensing Program Analyst (LPA), C. Fowler arrived unannounced to deliver complaint findings for the allegations above. LPA met with Administrator, Nolita David and explained the reason for the visit.

During the course of the investigation on the allegation facility does not maintain adequate food supply at facility, LPA observed a minimum 7-day non-perishables and 2-day perishable foods. Administrator provided LPA with a copy of the facility daily menu and grocery shopping list. Administrator also stated that she takes the residents out in the community to dine. During interview with clients all stated that they enjoy the food and are served 3 meals a day and snacks at the facility. Each client stated what their favorite foods are.

During interviews on the allegation staff hit clients, Administrator informed LPA that clients have never reported to her that they have been hit by staff, nor act as if they are afraid of staff
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Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
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-20220503133022
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: APPLETREE ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 079200150
VISIT DATE: 08/05/2022
NARRATIVE
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Continue from 9099

During interviews with clients C1 and C3 stated that they have never been hit by staff nor have staff said mean things to them. C2 stated that staff hit her and the other 2 clients as well. C2 also stated that staff is not mean to her. Due to C2 diagnosis LPA was not able to get a clear concise interview.

During interviews on the allegation of staff hit clients, S2 reported that she is an owner of an Adult Day Program and a mandated reporter, and stated if she had ever seen any abuse, she would have reported it. S2 has been on outings in the community dining with clients and often go for walks, S2 states clients would have told her if they had ever been hit.

Based on interviews and information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means 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.

Exit interview conducted and a copy of report was given.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2