079200625-7-22-2022-15-AS-KHOS-CHBSPW-20220815140349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200625
Report Date: 06/16/2022
Date Signed: 07/22/2022 08:09:35 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
05/10/2022 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20220510152635

FACILITY NAME:	MY FAMILY'S CARE HOME LLC		FACILITY NUMBER:	079200625
ADMINISTRATOR:	CAPUYAN, ISRAEL R		FACILITY TYPE:	740
ADDRESS:	2073 SOUTHWOOD DRIVE		TELEPHONE:	(510) 334-6933
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	4	CENSUS: 2	DATE:	06/16/2022
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Teresa Capuyan, Caregiver		TIME COMPLETED:	05:53 PM

ALLEGATION(S):

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Facility's fire alarms are not in operable condition.

INVESTIGATION FINDINGS:

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On 6/16/2022 at 3:45 am, Licensing Program Analysts (LPAs), C. Fowler and L. Hall arrived unannounced to conduct a complaint investigation and to deliver complaint findings for the allegation above. LPAs met with Teresa Capuyan, Caregiver and explained the reason for the visit. Administrator arrived at 4:25pm.

Allegation: Facility's fire alarms are not in operable condition.
Investigation Finding: UNSUBSTANTIATED
During investigation it was found that the fire alarm system is operational however S1 informed LPA Fowler that the strobe lights had been taped over. A citation will be issued under a separate case management report. The department has investigated the above allegation and determined it to be unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur.

Deficiency not cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

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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