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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200813
Report Date: 06/24/2022
Date Signed: 06/24/2022 02:25:17 PM

Unfounded


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
05/03/2022 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20220503124141
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:
06/24/2022
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Jane Bernardino, LicenseeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff refused to provide a meal to resident.
INVESTIGATION FINDINGS:
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On 06/24/22, Licensing Program Analysts (LPA) J Clancy-Czuleger conducted an unannounced subsequent visit and met with Licensee Jane Bernardino, to deliver the findings of above allegation. LPA explained the purpose of the visit with Licensee.

Investigation Finding: UNFOUNDED

During the course of the investigation, LPA Jill Clancy-Czuleger interviewed Administrator and 1 resident, and 1 witness. In the interview R1 stated that the facility does not cook for her, she cooks for herself. R1 stated she is sensitive to different foods and smells and does not like what the facility staff cooks so she makes her own food. When asked if she has ever been denied meals R1 responded “no I make my own”. LPA witnessed R1 using the kitchen during the investigation.

Continued on next page, LIC 9099-C
Unfounded
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: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
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 2
Control Number 15-AS-20220503124141
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: 06/24/2022
NARRATIVE
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 We have found that the complaint was unfounded, meaning that the allegation is without reasonable basis. Exit Interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2