079201008-12-29-2023-15-AS-KHOS-CZAQE6-20240108110551

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201008
Report Date: 12/29/2023
Date Signed: 12/29/2023 02:19:19 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
12/20/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20231220090620

FACILITY NAME:	TEMESCAL RESIDENTIAL CARE HOME CORP.		FACILITY NUMBER:	079201008
ADMINISTRATOR:	MELANIO, ANDRES JR JAGARAP		FACILITY TYPE:	740
ADDRESS:	4580 TEMESCAL COURT		TELEPHONE:	(925) 303-2959
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 1	DATE:	12/29/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Imelda Robles, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff are physically abusing resident(s) in care
Staff throw hot food at resident(s) in care

INVESTIGATION FINDINGS:

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On 12/29/23 at 11AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint investigation, gathered information, interviewed staff (ADM) and resident (R2) and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM.

At around 12:30PM & 1PM, LPA interviewed staff (ADM) & resident (R2) and collected the following documents: Resident roster with contact information, Personnel record (LIC500), admission agreements (R1, R2), physician’s reports, After discharge summary report (R1), incident reports, progress notes.

Continued on next page LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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-20231220090620

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: TEMESCAL RESIDENTIAL CARE HOME CORP.	FACILITY NUMBER: 079201008
	VISIT DATE: 12/29/2023

NARRATIVE

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Review of R1's admission agreement show she was first admitted at the facility on 10/12/23 from the hospital. LPA interviewed R1's family member (F1) who stated that she took care of R1 from September to October 2023 at her home prior to being admitted at the facility. F1 stated that R1 has undiagnosed mental health issues, and that R1 "is always accusing people of harming her" - adding that R1 has even lodged false accusations against her in the past.

During investigation, ADM stated that police has been called several times to the facility by R1 (once on 12/14/23 & three times on 12/16/23) regarding allegations of staff abuse to resident(s) in care. Based on earlier information given by police to the department on 12/20/23, R1 was observed to have no bruises or burn marks during several visits. R1's allegations of physical abuse was unfounded by police during investigation.

LPA also interviewed R2 who confirmed that staff do not abuse residents physically or neglect them. Review of R2's admission agreement show she has been living at the facility since 05/2021. Staff denied physically abusing residents or throwing hot food at any resident in care.

This department has investigated the allegations that staff physically abused resident(s) and threw hot food at resident(s). We have found that the complaint was unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited. Exit Interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC9099 (FAS) - (06/04)

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