079200814-9-25-2024-15-AS-KHOS-D9MJCR-20241001065622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200814
Report Date: 09/25/2024
Date Signed: 09/25/2024 03:39:16 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
09/17/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240917085531

FACILITY NAME:	SFBAY CARE - ANTIOCH		FACILITY NUMBER:	079200814
ADMINISTRATOR:	LIMJOCO, FREDDIE		FACILITY TYPE:	735
ADDRESS:	4956 SPUR WAY		TELEPHONE:	(415) 405-6503
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 4	DATE:	09/25/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Freddie Limjoco, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are engaging in inappropriate behaviors with residents
Staff left residents unattended
Staff are falsifying staff files
Staff are not meeting residents hygiene needs
Staff are bribing residents
Staff are not providing adequate food service to residents

INVESTIGATION FINDINGS:

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On 09/25/24 at 2:30PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit and delivered investigation findings to administrator (ADM). LPA explained the purpose of the visit with ADM.

At 2:40PM LPA interviewed staff (ADM, S1, S2) and clients (C1, C2, C3, C4). LPA also reviewed the following documents: Personnel record (LIC500), Clients’ roster, Staff third party health reports showing TB test results, staff training certifications (Relias), meal schedules/plans, groceries purchase receipts, Clients ISP/IPP plans/quarterly reports, admission agreements, behaviorist reports.

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: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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 4

Control Number 15-AS-20240917085531

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: 09/25/2024

NARRATIVE

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Allegation: Staff are engaging in inappropriate behaviors with residents
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ADM, S1, S2) and clients (C1, C2, C3, C4) who denied engaging in inappropriate behaviors. Clients (C1, C2, C3, C4) stated that staff do not give them alcohol or smoke weed. LPA observed the clients’ bedrooms and facility areas free of weed odors. LPA also observed no alcoholic drinks present at the facility on 09/12/24 and 09/20/24. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged occurred. Therefore, the allegation that staff are engaging in inappropriate behaviors with residents is unsubstantiated.

Allegation: Staff left residents unattended
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ADM, S1, S2) who stated they do not leave any client unattended. Clients (C1, C2, C3, C4) confirmed with LPA that staff are with them at all times at the facility or on outings. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff left residents unattended is unsubstantiated.

Allegation: Staff are falsifying staff files
Investigation Finding: Unsubstantiated
During investigation. LPA reviewed staff (ED, S1, S2) training certifications and physicians reports showing TB test results. LPA observed staff had written training certifications and TB test results signed and dated by third party agencies (Relias, Carbon Health) from 01/01/21 until 09/01/24. Staff denied falsifying medical records with LPA. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are falsifying staff files is unsubstantiated.

Continued on next page, LIC 9099-C1

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20240917085531

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: 09/25/2024

NARRATIVE

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Allegation: Staff are not meeting residents’ hygiene needs
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed client (C1) who stated that he is high functioning, independent and has the personal right to shower and bathe whenever he wants. C1 stated staff always (ADM, S1, S2) remind him to shower, change his clothes, do laundry, clean his room and do household chores such as wash dishes. LPA observed other clients (C2, C3, C4) to be ambulatory, clean, high functioning, independent, odor free and well groomed. During visit on 09/25/24 at 2:30PM, LPA observed C1 clean and odor free. C1 stated that he is working with his behaviorist in addressing his hygiene routines such as taking a shower more than twice a week, using Sensodyne toothpaste and electric brush in cleaning his teeth and routinely washing his clothes. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not meeting residents’ hygiene needs is unsubstantiated.

Allegation: Staff are bribing residents
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ED, S1, S2) who stated they do not bribe any client to clean. Clients (C1, C2, C3, C4) confirmed with LPA that staff do not bribe them to clean. Clients (C1, C2, C3, C4) stated staff do not offer them money to do household chores or clean their rooms at the facility. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are bribing residents is unsubstantiated.

Continued on next page, LIC 9099-C2

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20240917085531

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: 09/25/2024

NARRATIVE

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Allegation: Staff are not providing adequate food service to residents
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ED, S1, S2) who stated they purchase food supplies for clients’ meals every week and prepare meals as scheduled on their weekly meal plans. Clients (C1, C2, C3, C4) confirmed with LPA that staff provide them with adequate meals and that they are satisfied with the food service. On 0912/24, LPA observed kitchen refrigerator/freezer filled with fresh fruits, vegetables, eggs, sodas, milk and a variety of frozen meats. Fresh fruits were also observed on the kitchen dining table during visit. Clients stated they sometimes purchase food from their favorite restaurant if they do not like the food at the facility. Staff stated clients also have the option to select additional food from the pantry, freezer or refrigerator if they want. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not providing adequate food service to residents is unsubstantiated.

No deficiencies cited on this date. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

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