079200330-4-18-2023-15-AS-KHOS-CRLPFJ-20230507111650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200330
Report Date: 04/18/2023
Date Signed: 04/18/2023 02:46:37 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
04/10/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230410114755

FACILITY NAME:	BUENAVISTA HOME AT DAWNVIEW		FACILITY NUMBER:	079200330
ADMINISTRATOR:	ROBERTO S. PEREZ		FACILITY TYPE:	735
ADDRESS:	5514 DAWNVIEW CT.		TELEPHONE:	(925) 917-9640
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 5	DATE:	04/18/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Roberto Perez, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff hit client in care
Client(s) in care are not being accorded dignity in their personal relationship(s) with staff

INVESTIGATION FINDINGS:

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On 04/18/23 at 11AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with administrator (ADM), gathered information regarding the allegations and delivered investigation findings. LPA explained the purpose of the visit with ADM.

At 11AM, LPA conducted interviews (ADM, S1, S2, S3, C1, C3, C5) and collected the following documents: Clients' roster, Personnel record (LIC500), Clients' Needs & Services plans (ISP), weekly meal menus, monthly activity schedules and staff training certifications.

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: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230410114755

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: BUENAVISTA HOME AT DAWNVIEW	FACILITY NUMBER: 079200330
	VISIT DATE: 04/18/2023

NARRATIVE

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Allegation: Facility staff hit client in care
Investigation Finding: Unsubstantiated
Based on interviews and record reviews which were conducted, staff (ADM, S1, S2, S3) denied hitting or being abusive to any clients in care. Clients (C1, C2, C3) confirmed with LPA that they were treated well at the facility. C3 confirmed with LPA that staff do not hit him or other clients at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that facility staff hit client in care did occur, therefore the allegation is unsubstantiated.

Allegation: Client(s) in care are not being accorded dignity in their personal relationship(s) with staff
Investigation Finding: Unsubstantiated
During visit, LPA observed staff (ADM, S1, S2, S3) assist clients (C1, C2, C3) with meals, toileting and daily activities with no yelling, screaming or abusive behaviors toward clients in care. Staff stated they always treat their clients with dignity and respect. LPA observed staff (ADM, S1, S2, S3) talk to clients in a calm manner while assisting them with their activities. ADM stated hot food is always served to clients during mealtimes because they do not like frozen foods and will not eat them. Based on LPA’s observations and interviews which were conducted and record review(s), the department has investigated the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that clients in care are not being accorded dignity in their personal relationship(s) with staff did occur, therefore the allegation is unsubstantiated.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC9099 (FAS) - (06/04)

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