079200813-1-13-2023-15-AS-KHOS-CNLLXZ-20230131080933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200813
Report Date: 01/13/2023
Date Signed: 01/13/2023 01:55:11 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
06/15/2022 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20220615160447

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: 4	DATE:	01/13/2023
		UNANNOUNCED	TIME BEGAN:	01:02 PM
MET WITH:	Amabelle Amparo, Administrator		TIME COMPLETED:	02:06 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff retaliated against resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 01/13/2023 starting at 01:02 pm, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct complaint investigation for the above allegation. LPA met with Amabelle Amparo, Administrator and explained the purpose of the visit.

During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents. Based off intrviews and records reviews, LPA confirmed that R1 had made threataning coments to S1. S1 in fear made a call to the police to assist in the situation and they removed the resident for the facility to midigate the situation.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are 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: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

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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