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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200535
Report Date: 04/09/2025
Date Signed: 04/09/2025 07:43:37 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
01/14/2025 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20250114150807
FACILITY NAME:JOANGEL HAVENFACILITY NUMBER:
079200535
ADMINISTRATOR:SAN MATEO, JOSEFINA AFACILITY TYPE:
735
ADDRESS:4895 THIESSEN COURTTELEPHONE:
(925) 285-6411
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 4DATE:
04/09/2025
UNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Caregiver, Michael MallariTIME COMPLETED:
08:15 AM
ALLEGATION(S):
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 Licensee does not provide adequate food service for resident.
INVESTIGATION FINDINGS:
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On 4/9/2025 at 7:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings for the above allegation. LPA met with Caregiver, Michael Mallari and explained the purpose of the visit. Administrator unavailable.

During the course of the investigation LPA interviewed S1, the House Manager, and toured the kitchen. LPA also conducted a collateral visit to observe C1 at the day program and interviewed W1.

Report continues on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
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 3
Control Number 15-AS-20250114150807
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: JOANGEL HAVEN
FACILITY NUMBER: 079200535
VISIT DATE: 04/09/2025
NARRATIVE
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LPA observed on 1/24/2025 the kitchen to be fully stocked with a variety of food. LPA was also shown photos of clients meals that they take with them to the programs. On 1/24/2025 LPA also conducted a collateral visit to observe R1 at the day program. LPA observed that R1 had a lunch of chicken, rice, and fruits. On 1/24/2025 LPA interviewd W1. W1 was able to show LPA a photo from 10/31/2024 where the clients lunch was a burrito and pizza rolls. LPA did observe that there was a spot of mold on the burrito about the size of an eraser on a pencil. W1 states that since the incident with the moldy burrito the facility has gotten better with sending nutritious lunches. On 4/9/2025 LPA spoke with the House Manager(HM) over the phone who states that in March of 2024 they were made aware by the day day program that they sent a moldy hot pocket. HM states that was the only time moldy food was sent and that they threw away the rest of the hot pockets. HM also stated that after LPA's first visit on 1/24/2025 the facility started serving more vegetables to clients. Although at the time of the visit the facility was serving adequate meals to residents in care it was found through interviews and photos that the facility had previously provided moldy food to residents therefore the allegation " Licensee does not provide adequate food service for resident." is substantiated.

Administrator approved caregiver to sign the report with LPA over the phone.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20250114150807
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JOANGEL HAVEN
FACILITY NUMBER: 079200535
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2025
Section Cited
CCR
80076(a)(1)
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(a) In facilities providing meals... the following shall apply:(1) All food shall be safe ... and served in a safe and healthful manner.

This requirement was not met as evidence by:
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Facility is now serving food of good quality and balance. POC clear.
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Based on observation and interview, the licensee did not comply with the section cited above by providing client/resident with moldy food which posed a potential health risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3