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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200814
Report Date: 03/01/2022
Date Signed: 03/01/2022 04:26:22 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
02/22/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220222113446
FACILITY NAME:SFBAY CARE - ANTIOCHFACILITY NUMBER:
079200814
ADMINISTRATOR:LIMBO, JOSEPHINEFACILITY TYPE:
735
ADDRESS:4956 SPUR WAYTELEPHONE:
(415) 405-6503
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 4DATE:
03/01/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Freddie Limjoco, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff threatened resident
INVESTIGATION FINDINGS:
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On 03/01/22 at 2PM, Licensing Program Analysts (LPAs) Daisy Panlilio and Liridon Fici conducted an unannounced complaint investigation, met with staff (DSP) and spoke to administrator (ADM) on the phone who authorized DSP to act on his behalf and sign the reports. LPAs explained the purpose of the visit with ADM and DSP.

During investigation, LPAs interviewed staff (ADM, DSP) and clients (C1, C2). ADM gave a copy of the regional center of the east bay (RCEB) incident report dated 02/12/22 which documents that an altercation occurred between C1 and 3 staff trainees regarding the driveway parking space in front of the facility. Staff trainees told C1 that they have permission from ADM to use the parking space. C1 got upset and started calling names at the staff trainees. In retaliation, staff trainee (ST2) told C1 to keep quiet before he gets "whooped". Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
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 3
Control Number 15-AS-20220222113446
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: SFBAY CARE - ANTIOCH
FACILITY NUMBER: 079200814
VISIT DATE: 03/01/2022
NARRATIVE
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Based on LPAs observations and interviews which were conducted and record review(s), ADM confirmed staff trainee (ST2) threatened C1 when he told client to keep quiet before he gets "whooped". LPAs interview with C2 also confirms C1 had an altercation with the staff trainees and that staff trainee driver (ST2) threatened C1. Review of the RCEB incident report dated 02/12/22 corroborates the incident happened.

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.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220222113446
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: SFBAY CARE - ANTIOCH
FACILITY NUMBER: 079200814
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2022
Section Cited
CCR
80072(a)(1)
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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by
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Administrator agreed to re-train staff on how to properly redirect client's behavior at all times.

By POC due date, Administrator agreed to submit to CCLD completed staff retraining
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staff trainee threatening resident which posed a potential health & safety risk to residents in care.
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staff retraining certifications on proper care and supervision of clients 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3