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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200543
Report Date: 09/29/2022
Date Signed: 09/29/2022 11:18:38 AM

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
07/14/2022 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20220714121257
FACILITY NAME:A BLISSFUL RETREAT, LLCFACILITY NUMBER:
079200543
ADMINISTRATOR:OSMAN, SUMAIYAFACILITY TYPE:
740
ADDRESS:4200 COWELL ROADTELEPHONE:
(925) 726-8888
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 5DATE:
09/29/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Olivia Siu, AdministratorTIME COMPLETED:
11:28 AM
ALLEGATION(S):
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9
Facility staff do not serve nutritious meals
Facility does not have adequate meal amount of food for the residents in care
INVESTIGATION FINDINGS:
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3
4
5
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9
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On 09/29/2022 at 10:35 AM, Licensing Program Analysts (LPA), J. Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegations. LPA met with Olivia Siu, Administrator and explained the reason for the visit.

During the course of investigation, based on initial visit, LPA observed sufficient amount of food for clients in care. The staff provided a grocery list and meal menu for the month. LPA observed instructions for staff regarding the refrigerator and their personal use. Based on interviews with staff stated that the facility has the care staff cooks the meals for all the residents.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
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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