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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200813
Report Date: 03/10/2023
Date Signed: 03/10/2023 09:20:12 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
05/05/2022 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20220505152444
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: 4DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Amabelle Amparo, CaregiverTIME COMPLETED:
09:35 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff restrained resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/10/2023 at 09:05 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings for the complaint investigation for the above allegation. LPA met with Amabelle Amparo, Caregiver and explained the purpose of the visit.

During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents. Based off interview’s, LPA confirmed that R2 was trying to climb out the window and S3 was trying to prevent R2 from falling.

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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
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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