<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200861
Report Date: 06/23/2023
Date Signed: 06/23/2023 12:39:35 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
06/01/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230601140053
FACILITY NAME:GAENOR HOME INCFACILITY NUMBER:
079200861
ADMINISTRATOR:NORIEGA, DIONEILFACILITY TYPE:
735
ADDRESS:1754 SATTLER DRTELEPHONE:
(925) 332-7907
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 6DATE:
06/23/2023
UNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Ernesto Ortigas, CaregiverTIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained injuries due to staff neglect
Staff did not seek medical attention for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 06/23/2023 starting at 12:24 pm, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings for the complaint investigation for the above allegations. LPA spoke with Administrator Dioneil Noriega and explained the purpose of the visit. Dioneil designated his caregiver Ernesto Ortigas to sign off on the report.

On the allegation Resident sustained injuries due to staff neglect: R1’s medical history shows that R1 has a history of self-harming behaviors of hitting his left bicep when he is stressed and upset. Based on interview with staff, R1 has a close connection with S2. S2 was on vacation for the month of May, and it caused R1 to have an increase in the self-harming behaviors until S2 came back.

Continued on 9099C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
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-20230601140053
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: GAENOR HOME INC
FACILITY NUMBER: 079200861
VISIT DATE: 06/23/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
...Continued from 9099

On the allegation Staff did not seek medical attention for resident: Based on interview with staff and W1 and record reviews R1 does not have a history of UTI’s and drinks water regularly throughout the day. All of the staff stated that if there was any kind of medical issues, they would contact the residents doctor or call 9-1-1 in an emergency situation.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2