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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 03:39:13 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
09/17/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240917085516
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:
03:15 PM
MET WITH:Koryn Itibus, Direct Support StaffTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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9
Staff left residents unattended
INVESTIGATION FINDINGS:
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13
On 12/23/2024 at 3:15pm, 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, toured kitchen, and reviewed and obtained records.

Allegation: Staff left residents unattended

Based on interviews with staff and client. This allegation was substantiated and cited on complaint 15-AS-20240507154912 dated 05/07/2024.

Exit interview conducted a copy of this report provided.
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 3
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 Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240917085516

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:
03:15 PM
MET WITH:Koryn Itibus, Direct Support StaffTIME COMPLETED:
03:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared staff providing care to the residents
Staff are engaging in inappropriate behaviors with residents
Staff are falsifying staff files
Staff are not able to effectively communicate with residents
Staff are not providing adequate food service to residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/23/2024 at 3:15PM, 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, toured kitchen, and reviewed and obtained records.

Allegation: Staff are not providing adequate food service to residents

Based on interviews with client, staff, and observation this allegation was unsubstantiated on complaint 15-AS-20240507154912 on 05/07/2024. During observation on 9/20/2024 LPA observed a 7-day supply of perishable and 2-day perishable foods. C1 stated there is food at the facility. C1 also stated that he buys his own special foods, and there are times the facility buys food from a restaurant.

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: 2 of 3
Control Number 15-AS-20240917085516
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: Uncleared staff providing care to the residents

Based on interview with W1 facility is employing staff to care for clients but not making sure they are eligible. LPA checked facility staff schedule against guardian and observed all staff on schedule is cleared and associated to the facility.

Allegation: Staff are engaging in inappropriate behaviors with residents

Based on interview with W1 staff smoke marijuana and drinks alcohol with client. LPA interviewed client and staff on complaint 15-AS-20240507154912 on 05/07/2024. S1, S2, S3, and C1 all stated that staff do not smoke with client.

Allegation: Staff are falsifying staff files

W1 stated on initial interview that the facility was falsifying files. W1 stated during additional interview that W1 heard somebody say files were being falsified, W1 did not witness anything. LPA reviewed client and S1, S2, S3, and S4 files and all appear to be originally signed and not falsified.

Allegation: Staff are not able to effectively communicate with residents

W1 stated during interview that there is a male and female that is not able to communicate with residents but W1 was unable to provide names. Client stated during interview that he does not have a problem communicating with any of the staff. LPA interviewed S2, S3, and S4, none of the staff had a problem with communication.

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 given.

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: 3 of 3