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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200150
Report Date: 02/18/2025
Date Signed: 02/18/2025 12:30:46 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
02/12/2025 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20250212130200
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: 2DATE:
02/18/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:NOLITA DAVID, ADMINISTRATORTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff prevent residents from making/receiving phone calls
Staff do not ensure that resident is able to receive visitors
INVESTIGATION FINDINGS:
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On 02/18/2025 at 10:00 am, Licensing Program Analyst (LPA), C. Fowler arrived unannounced to open a 10 day initial complaint 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 Staff prevent residents from making/receiving phone calls, LPA conducted interviews with W1, S1, S2 and C1. Administrator provided LPA with a copy of house rules and Identification and Emergency Information. Administrator stated that the facility is following HCBS Federal Regulations, and clients have the right to have private phone calls. Administrator stated that C1 has a cell phone and family has C1 cell phone phone number, and C1 has privacy on the phone. During interview with C1 it is revealed that C1 will sometimes answer the phone if C1 wants to and will talk with callers and family members. C1 stated that C1 has informed W1 that C1 dose not want to have anything to do with W1. C1 stated that S1 dose not listen to or direct C1 on what to say to family or anyone on C1 phone calls.

Continue on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
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-20250212130200
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: 02/18/2025
NARRATIVE
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Continue from LIC 9099

During the course of the investigation on the allegation Staff do not ensure that resident is able to receive visitors. LPA conducted interviews with W1, S1, S2 and C1.

During interviews on the allegation Staff do not ensure that resident is able to receive visitors, S1 reported that there was a visitor that came to the house for C1 and C1 informed S1 that C1 didn't want to visit with the visitor. Interview with C1 revealed that C1 didn't want to visit with the visitor so the door was not answered. Interview with S2 stated that the facility allows visitors at anytime due to HCBS Federal Regulation. S2 also stated that C1 often has a change of mind and C1 might want a visit or might not just depending on what's on C1's mind. S2 also stated that S2 didn't recall C1 ever having visitors.

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.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2