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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200813
Report Date: 05/12/2022
Date Signed: 05/12/2022 05:50:46 PM

Substantiated


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
12/13/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211213165524
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:
05/12/2022
UNANNOUNCEDTIME BEGAN:
05:13 PM
MET WITH:Jane Bernardino, AdministratorTIME COMPLETED:
06:20 PM
ALLEGATION(S):
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Staff is disrupting resident's sleep
INVESTIGATION FINDINGS:
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On 05/12/22 at 5:13PM, 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 allegations. LPA explained the purpose of the visit with administrator.

Based on interviews and record reviews, staff (S1, S3, S5) confirmed with LPA that during meal breaks they reheat food at the facility at various intervals. Resident (R1) is sensitive to smell and has complained to staff that her sleep is disrupted due to the pungent smell of food coming from the kitchen which is adjacent to her bedroom.
Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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)
Page: 1 of 6
Control Number 15-AS-20211213165524
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2022
Section Cited
CCR
87468.1(a)(3)
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Personal Rights
Residents in all residential care facilities for the elderly shall have all of the following personal rights (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination
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By POC due date, administrator agreed to submit to CCLD proof of correction of completed in-service staff retraining on residents’ personal rights.
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This requirement was not met as evidenced by staff disrupting resident's sleep due to reheating food during meal breaks which posed a potential health & safety risk to resident in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
12/13/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211213165524

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:
05/12/2022
UNANNOUNCEDTIME BEGAN:
05:13 PM
MET WITH:Jane Bernardino, AdministratorTIME COMPLETED:
06:20 PM
ALLEGATION(S):
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Staff is not administering medications as prescribed by physician
Staff locked resident out of the house
Staff is harassing resident
Staff withholds residents’ mail
Facility is in disrepair
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 allegations. LPA explained the purpose of the visit with administrator.

Allegation: Staff is not administering medications as prescribed by physician
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, LPA observed resident’s (R1’s) signed medication assistance (MARs) records and PRN medication logs dated January 2020 thru May 2022 show R1 received medications from staff as prescribed by her physician. LPA observed R1’s prescription refill records matched MAR prescription dosages and medications. 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.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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)
Page: 3 of 6
Control Number 15-AS-20211213165524
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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Allegation: Staff locked resident out of the house
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, staff (S1) stated that resident (R1) would go out on walks or run errands. LPA’s review of R1’s progress notes dated 11/05/2021 stated that staff (S4) saw R1 outside the facility door and reported that she was locked out at the other facility where she resides and could not get inside. Staff (S4) stated she accompanied R1 back to the facility, found the door unlocked , opened the door and let R1 inside the facility. S4 witnessed R1 talk to staff (S2). 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.

Allegation: Staff is harassing resident


Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, staff (S3, S5) denied harassing resident (R1). Interviews conducted by LPAs with other residents confirm staff do not yell or harass them. Interviews with staff (S1, S3, S5) denied harassing R1. 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.

Allegation: Staff withholds residents’ mail
Investigation Finding: UNSUBSTANTIATED
During investigation, staff (S1) stated that all residents’ mails are distributed by staff daily. S1 stated there was only one occasion wherein resident’s (R1’s) letter was found to be inadvertently inserted in the weekly supermarket advertising magazines which was overlooked. Upon discovery, staff immediately handed the letter to R1. S1 stated there was no intention to withhold any mail from any resident and have instructed staff to go through all magazines to ensure it will not happen again. Interviews with other residents confirm they receive their mail from staff. 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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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)
Page: 4 of 6
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
12/13/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211213165524

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:
05/12/2022
UNANNOUNCEDTIME BEGAN:
05:13 PM
MET WITH:Jane Bernardino, AdministratorTIME COMPLETED:
06:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff tampered with resident’s food
INVESTIGATION FINDINGS:
1
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3
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5
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7
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9
10
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13
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 allegations. LPA explained the purpose of the visit with administrator.

Allegation: Staff tampered with resident’s food
Investigation Finding: UNFOUNDED
During investigation, LPA observed all residents’ food were kept in separate containers and stored in a common refrigerator located in the kitchen on 12/14/2021. Licensee stated a new refrigerator was purchased on 09/22/2021 solely for R1’s use to accommodate her desire to prepare her own meals. However, R1 still stores her food containers in the common refrigerator with sticky notes. Cleaning of the common refrigerator is done regularly by staff to ensure food safety and as a result, food containers are moved from their original storage positions and R1’s food container sticky notes come off due to moisture inside the refrigerator. This led R1 to believe that her food is being tampered with. Staff denied they tampered with R1’s food. This department had investigated the complaint alleging that staff tampered with resident’s food. We have found that the complaint was unfounded, meaning that the allegation is without reasonable basis.

Continued on next page, LIC 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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)
Page: 5 of 6
Control Number 15-AS-20211213165524
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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Allegation: Facility is in disrepair
Investigation Finding: UNSUBSTANTIATED
During investigation, LPA toured the facility with staff (S3, S5, S6) on 12/14/2021. LPA observed the facility clean, in good repair and odor free. LPA also observed common refrigerator in the kitchen had R1’s food containers with sticky notes stored inside along with other residents’ food. Administrator also showed LPA the new refrigerator purchased for R1 so she can store her food separate from the other residents. 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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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)
Page: 6 of 6