079200813-8-11-2022-15-AS-KHOS-CJW6ZZ-20221004211557

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200813
Report Date: 08/11/2022
Date Signed: 08/11/2022 02:23:58 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
02/28/2022 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20220228162201

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:	DATE:	08/11/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Gladys Enriquez, Administrator		TIME COMPLETED:	01:31 PM

ALLEGATION(S):

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Facility administrator yelled at resident.

INVESTIGATION FINDINGS:

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On 08/11/2022 at 1:25 PM, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA met with Administrator Gladys Enriquez and explained the purpose of the visit.

During the course of the investigation, LPA L. Francisco obtained information, collected documents, and interviewed residents and staff. Based on information obtained by complainant, facility administrator yelled at resident. However, S1 denied yelling at resident. During an interview with S1, LPA L. Francisco discovered resident approached S1 to talk to her while S1 was unloading groceries, and S1 told resident to wait. According to S1, since she was wearing a mask, she needed to increase the volume of her voice because resident has a hard of hearing.

REPORT CONTINUES TO 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

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-20220228162201

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: 08/11/2022

NARRATIVE

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LPA interviewed 3 residents, 3 of 3 residents denied witnessing staff yelling at other residents. LPA was unable to prove or disprove allegation.

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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC9099 (FAS) - (06/04)

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