079200813-7-20-2022-15-AS-KHOS-CHCKW8-20220816081532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200813
Report Date: 07/20/2022
Date Signed: 07/20/2022 11:55:39 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
01/03/2022 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220103090834

FACILITY NAME:	GABRIEL'S HOUSE 1		FACILITY NUMBER:	079200813
ADMINISTRATOR:	BERNARDINO, JANE PABUSTAN		FACILITY TYPE:	740
ADDRESS:	3109 CONCORD BLVD		TELEPHONE:	(925) 470-7160
CITY:	CONCORD	STATE: CA	ZIP CODE:	94519
CAPACITY:	6	CENSUS: 5	DATE:	07/20/2022
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Gladys Min Enriquez, Administrator		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff failed to provide adequate food service
Staff failed to treat resident with dignity and respect

INVESTIGATION FINDINGS:

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On 7/20/2022 at 9:20AM, Licensing Program Analysts (LPAs) G. Luk and J. Clancy-Czuleger arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPAs met with Administrator, Gladys Min Enriquez and informed her the reason for the visit.

During the course of investigation, LPA G. Luk interviewed 3 residents, 3 staff, and 2 witnesses. LPA also reviewed documents including facility menu and physician's reports for 3 residents.

Staff failed to provide adequate food service:
Interview with residents and witnesses revealed that three meals are provided to the residents. Witnesses stated facility foods were home cooked, healthy, and no meals were missed. Interview with staff indicated that one resident cooks their own food and staff provides 3 meals for the other 2 residents. However, if any residents ask for food, staff will provide it to the residents. (Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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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Control Number 15-AS-20220103090834

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: GABRIEL'S HOUSE 1	FACILITY NUMBER: 079200813
	VISIT DATE: 07/20/2022

NARRATIVE

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Staff failed to treat resident with dignity and respect:
Interview with witnesses revealed that staff are tentative and providing great care to the residents. Witnesses stated that staff are polite and have not witnessed any staff be rude or ignored a resident. Residents stated that staff are nice and not rude to residents.

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

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC9099 (FAS) - (06/04)

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