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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200813
Report Date: 07/27/2022
Date Signed: 07/27/2022 02:39:28 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
02/16/2022 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20220216122111
FACILITY NAME:GABRIEL'S HOUSE 1FACILITY NUMBER:
079200813
ADMINISTRATOR:BERNARDINO, JANE PABUSTANFACILITY TYPE:
740
ADDRESS:3109 CONCORD BLVDTELEPHONE:
(925) 470-7160
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 5DATE:
07/27/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Gladys Enriquez, Assistant AdministratorTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Staff sprayed strong smelling chemicals outside resident's door.
INVESTIGATION FINDINGS:
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On 7/27/2022 at 12:00 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA met with Care Staff, Celia Clet and LPA explained the purpose of the visit. Assistant Administrator, Gladys Enriquez later arrived at 12:48 PM.

During the course of the investigation, LPA obtained information, interviewed staff and residents. Based on information obtained, Staff sprayed strong smelling chemicals outside resident's door. However, LPA discovered during an interview with 6 staff, 6 of 6 staff denied spraying strong smelling chemicals outside resident's door.


REPORT CONTINUES ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
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-20220216122111
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: 07/27/2022
NARRATIVE
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According to staff interviews, 4 of 6 staff mixes the floor cleaner with water and opens the windows when they are mopping the floor near the residents rooms. LPA interviewed 3 residents, and 3 of 3 residents stated they are not bothered by the chemical smell.

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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2