079200940-12-27-2021-15-AS-HHUL-CJ2VFT-20220907162429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200940
Report Date: 12/27/2021
Date Signed: 12/27/2021 05:12:42 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
12/22/2021 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20211222084738

FACILITY NAME:	NEW ALAMO RESIDENCE HOME		FACILITY NUMBER:	079200940
ADMINISTRATOR:	SAXENA, MEERAN		FACILITY TYPE:	740
ADDRESS:	836 STONE VALLEY RD		TELEPHONE:	(925) 743-1565
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	6	CENSUS: 6	DATE:	12/27/2021
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Meeran Saxena, Administrator		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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Registered Sex Offender(RSO) is allegedly associated or present at the facility

INVESTIGATION FINDINGS:

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On 12/27/2021 at 3:15 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. LPA was greeted by Rosalina Bermudas. LPA later met with Administrator, Meeran Saxena at 3:30 PM.

During course of the investigation, the Department conducted interviews with Administrator, RSO and Witness. Documents including but not limited to: Signed 10-day Notification, RSO’s Driver’s License, Department of Justice Fingerprint Response, and Facility Safety Plan were obtained.

**REPORT CONTINUES ON 9099C**

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20211222084738

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: NEW ALAMO RESIDENCE HOME	FACILITY NUMBER: 079200940
	VISIT DATE: 12/27/2021

NARRATIVE

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On 12/21/2021, The Department observed Registered Sex Offender (RSO), Pedro Omar at the facility. Based on interview with Administrator, RSO has been residing and employed at the facility since 11/15/2021. RSO reported to the Department that he has been living and working at the facility since 11/05/2021. Administrator submitted live scan for RSO. However, status of RSO was pending. According to RSO, he informed Administrator that he is a registered sex offender. However, Administrator denied she had knowledge, but was aware he had criminal background. A safety plan was provided to the Department by Administrator on 12/21/2021. On 12/22/2021, the Department was informed by Administrator that RSO has left the facility. LPA L. Francisco confirmed RSO is not present at facility during today’s visit on 12/27/2021.

Based on evidence obtained during the course of this investigation, the Department has substantiated Registered Sex Offender(RSO) is allegedly associated or present at the facility licensed by the Department. This is a factual determination based on all the facts and circumstances of the case. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Health and Safety Code is being cited on the attached LIC 9099D.

An immediate $500 Civil Penalties is being assessed.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021

LIC9099 (FAS) - (06/04)

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Citations on this Visit Report are Under Appeal!

Control Number 15-AS-20211222084738

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: NEW ALAMO RESIDENCE HOME	FACILITY NUMBER: 079200940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type A 12/28/2021 Section Cited HSC 1569.17(c)(3)	1 2 3 4 5 6 7	1569.17(c)(3) Fingerprints and criminal records.. (3)…If the State Department of Social Services determines, on the basis of the fingerprint images submitted to the Department of Justice, that the person has been convicted of a sex offense against a minor…. the receipt of the notification from the Department of Justice to act immediately to terminate the person’s employment, remove the person from the residential care facility for the elderly….”	1 2 3 4 5 6 7	Administrator will review regulation and submit a self certification letter of understanding to CCL by POC date. AN IMMEDIATE $500 CIVIL PENALTY IS BEING ASSESSED.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on evidence obtained during the course of this investigation, Licensee did not comply with the regulation cited above. The Department observed RSO present at the facility on 12/21/2021 which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021

LIC9099 (FAS) - (06/04)

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