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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200571
Report Date: 04/22/2024
Date Signed: 04/22/2024 03:53:47 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
04/16/2024 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20240416121706
FACILITY NAME:BUENAVISTA HOME AT MIRA VISTAFACILITY NUMBER:
079200571
ADMINISTRATOR:PEREZ, RONALDO SFACILITY TYPE:
735
ADDRESS:3490 SWALLOW COURTTELEPHONE:
(925) 757-9880
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 6DATE:
04/22/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Zaldy Valdez, Direct Support ProfessionalTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Staff was unable to drive a resident in a car in a safe manner.
INVESTIGATION FINDINGS:
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On 4/22/2024 at 2:15pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a complaint investigation and to deliver complaint findings for the allegation above. LPA met with Zaldy Valdez, Direct Support Professional, and explained the reason for the visit. LPA spoke with Administrator, Ronaldo Perez, via telephone.

During the investigation LPA interviewed staff and collected after summary visit for C1. S1 will email a copy of the incident report that was submitted.

RP stated during initial interview that RP felt the staff member could not drive C1 back to the facility from the visit. Based on interview with S2 he was sitting with hand on

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
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-20240416121706
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 MIRA VISTA
FACILITY NUMBER: 079200571
VISIT DATE: 04/22/2024
NARRATIVE
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Continued from LIC9099.

his head with eyes closed because they had been at visit for almost two (2) hours, but was not asleep. S2 stated he sat up as soon as he heard doctor in the room. S3 stated during interview that he received a call from Sutter urgent care but was not able to obtain who the caller was. S3 stated he had told the caller they could call S1. S1 stated he was able to obtain more information from the caller and sent S3 to Sutter, but did not feel that S2 had any issue. S1 also stated he asked the caller what was the diagnosis of S2 and did not receive a response. S3 arrived, was able to go into room with S2 and C1, and stated both seemed very scared. After speaking with the urgent care staff S3 stated the security guard asked was it okay for S2, S3, and C1 to leave and was told yes. C1 rode with S3 back to the facility.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2