079200813-7-27-2022-15-AS-KHOS-CJW46W-20221004185015

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200813
Report Date: 07/27/2022
Date Signed: 07/27/2022 02:38:05 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-20220216155120

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:	07/27/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Gladys Enriquez, Assistant Administrator		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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9

Facility staff did not respond to resident's call for assistance.

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, collected documents, interviewed residents and staff. Based on information obtained, facility staff did not respond to resident's call for assistance. However, S4 stated once she heard R1 yelling for help, S4 went to check on R1 followed by S5. LPA interviewed 3 residents and 3 of 3 stated staff responds to their call when they need assistance.

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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (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)

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