079200813-5-12-2022-15-AS-BFOG-CF2TFT-20220603144204

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200813
Report Date: 05/12/2022
Date Signed: 05/12/2022 05:03:39 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
05/11/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220511145824

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:	05/12/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Jane Bernardino, Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Resident was locked inside her room

INVESTIGATION FINDINGS:

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On 05/12/22, Licensing Program Analysts (LPAs) D Panlilio and J Clancy-Czuleger conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegation. LPA explained the purpose of the visit with administrator.

Based on interviews and record reviews, resident (R1) stated that on 10/31/2021, her bedroom door handle broke, could not get out of her room and ended up calling 911. LPA’s review of staff’s (S3, S5) incident report dated 10/312021 show that at 6:30PM that night, they opened the window and exhaust fan in the kitchen to lessen the smell of food while preparing their dinner. S3 stated that R1 got out of her room at 7:10PM and witnessed her place a towel against her door and slammed it. At around 7:40PM, S3 witnessed R1 get out of her room again and opened the doors angrily.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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-20220511145824

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: 05/12/2022

NARRATIVE

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Staff stated R1 returned to her room and around 7:42PM started hitting the door and shouting hysterically for help while inside. S3 stated she went outside to look at her by the window to check on how she was doing. S3 stated she went back to R1’s door again and heard R1 call someone on the phone. S3 stated she opened R1’s door and left R1’s door open while she called the administrator at 8PM to report the incident.

At 8:15PM, staff stated a police officer came as well as the emergency responders (EMT). Staff stated R1 refused to leave the facility with EMT and told them she was OK and safe. Staff denied locking R1 inside her room.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated. Exit Interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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