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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200914
Report Date: 12/23/2024
Date Signed: 12/23/2024 03:36:27 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
05/07/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240507154912
FACILITY NAME:HARBOUR PLACE LLCFACILITY NUMBER:
079200914
ADMINISTRATOR:LIMJOCO, ALFREDOFACILITY TYPE:
735
ADDRESS:3000 HARBOUR DRIVETELEPHONE:
(415) 239-8145
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 1DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Koryn Itibus, Direct Support StaffTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff leave clients unsupervised.

Staff are not properly qualified to care and supervise clients in care.
INVESTIGATION FINDINGS:
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On 12/23/2024 at 2:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Koryn Itibus, Direct Support Staff and explained the purpose of the visit.

During the investigation the LPA interviewed staff, the client, and reviewed records.

Allegation: Staff leave clients unsupervised.

Based on interview with W1 client is left unsupervised at times. The During the interviews with the staff S1 stated there is always someone at the facility with the clients. S3 and S5 stated the client may be left for 10 or 20 minutes. C1 stated during

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
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 5
Control Number 15-AS-20240507154912
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: HARBOUR PLACE LLC
FACILITY NUMBER: 079200914
VISIT DATE: 12/23/2024
NARRATIVE
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*This is an amended report from 12/23/2024 to add civil penalties*


Continued from LIC9099.

interview that staff leaves him alone all the time. C1 stated that most of the time he doesn’t want to go on the outings with the other facilities and he stays at home without supervision.

Allegation: Staff are not properly qualified to care and supervise clients in care.

Witness stated during initial interview that staff are unqualified to care for clients. Based on record review LPA observed 3 of 5 staff did not have a health screening or first aid certification, which two (2) were working at the time of the visit.

*A civil penalty of $500.00 was assessed for lack of supervision*

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of the appeal right, LIC421M, and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20240507154912
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: HARBOUR PLACE LLC
FACILITY NUMBER: 079200914
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2024
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement was not met as evidence by:
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Administrator agreed to read regulation 80078 and submit self-certificaton that going forward facility will abide by regulation and submit certification to CCLD by POC date.
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Based on interviews the licensee did not comply with the seciton cited above in properly supervising client, which poses a potential health and safety risk to persons in care.
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*A $500.00 civil penalty was assessed*
Type B
01/06/2025
Section Cited
CCR
80066(a)
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80066 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement was not met as evidence by:
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Administrator agreed to obtain a health screening and first aid certification for every employee and submit a copy to CCLD by POC date.
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Based on record review the licensee did not comply with the seciton cited above in having health screening and first aid for all staff which poses a potential health and safety risk for persons 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
05/07/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240507154912

FACILITY NAME:HARBOUR PLACE LLCFACILITY NUMBER:
079200914
ADMINISTRATOR:LIMJOCO, ALFREDOFACILITY TYPE:
735
ADDRESS:3000 HARBOUR DRIVETELEPHONE:
(415) 239-8145
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 1DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Koryn Itibus, Direct Support StaffTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff smokes marijuana with clients in care.

Staff drink alcohol and smoke marijuana while caring and supervising clients.

Staff bribe clients in care.

Staff do not provide adequate food service to clients.
INVESTIGATION FINDINGS:
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On 12/23/2024 at 2:45pm Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Koryn Itibus, Direct Support Staff and explained the purpose of the visit.

During the investigation the LPA interviewed staff, the client, and reviewed records.

Allegation: Staff smokes marijuana with clients in care.

S1, S2, and S3 stated during interview that staff do not smoke with client. C1 stated he does smoke marijuana and he know which staff smokes, but none of them smoke with him.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240507154912
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: HARBOUR PLACE LLC
FACILITY NUMBER: 079200914
VISIT DATE: 12/23/2024
NARRATIVE
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Continued from LIC9099.

Allegation: Staff drink alcohol and smoke marijuana while caring and supervising clients.

Based on interview with staff, none of the staff stated that they drink and smoke during working hours. C1 stated one (1) of the staff if live-in and does smoke but not during shift. S1 stated he never came to facility and observed any drinking or smoking during shift.

Allegation: Staff bribe clients in care.

Witness stated during initial interview that staff bribes client. S3 stated that there have been a few times were C1 is offered money to clean his room, but it wasn’t a bribe just an incentive. C1 stated that he has received money to help with certain things around the facility. C1 stated he doesn’t feel it was a bribe he was working for something.

Staff do not provide adequate food service to clients.

Initial interview with witness stated there is not enough food for clients. LPA toured kitchen and observed there was enough food being there is only one (1) client at the facility. C1 stated during interview that facility has food, but C1 also buys food. Staff will take C1 to the grocery store to buy specific foods. C1 also stated that the facility sometimes buys food from restaurants.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5