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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200916
Report Date: 05/08/2025
Date Signed: 05/08/2025 03:06:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
03/13/2025 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20250313150916
FACILITY NAME:OUR HOMEFACILITY NUMBER:
079200916
ADMINISTRATOR:BANSIL, REYNANTEFACILITY TYPE:
735
ADDRESS:9692 TAREYTON AVENUETELEPHONE:
(510) 220-6712
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 5DATE:
05/08/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Lead staff, Eumelia MendozaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff restrained resident
INVESTIGATION FINDINGS:
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On 5/8/2025 Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver complaint investigation findings. LPA met with Lead staff, Eumelia Mendoza and explained the purpose of the visit. Administrator was unavailable.

During the course of the investigation LPA interviewed S1. LPA obtained trainings for S1, S2, IPP/ Careplan for C1, all corespondences regarding C1, and all medical documentation for C1. It was found durring the investigation that S1 and S2 restrained C1 durring a blood draw appointment.

report continues on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
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-20250313150916
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: OUR HOME
FACILITY NUMBER: 079200916
VISIT DATE: 05/08/2025
NARRATIVE
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When LPA interviewed S1 on 3/19/2025 S1 stated that 2 staff restrained C1. S1 states that they restrained C1 with S2. S1 states that C1 is strong which is why they both restrained C1. S1 states that they do not typically restrain resident but that they did that one time for the blood draw. S1 states that they have been trained on how to do restraints in 2024. S1 was unable to tell LPA the name of the restraints they were trained on. S1 states that that they were holding down C1's arm and shoulders while they were getting their blood drawn but can't remember how S2 was restraining C1. On 3/19/2025 LPA briefly spoke with Administrator who states that they were aware of S1 and S2 restraining C1.

LPA reviewed the care plan for C1 and also reviewed correspondences from regional center regarding C1 and found that C1 was not supposed to be restrained by staff and that it was not approved for the blood draw.

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 and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20250313150916
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OUR HOME
FACILITY NUMBER: 079200916
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2025
Section Cited
CCR
85168.2(a)
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(a) If the licensee will use ... manual restraint ... licensee shall develop an individual emergency intervention plan for that client.

This requirement was not met as evidence by:
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By POC Facility agrees to review the regulation and if neccessary take steps to develop a plan for C1 and notify CCLD.
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Based on record review and interview C1 was mannualy retrained without a proper plan in place which posed a potential safety and personal rights risk to client 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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3