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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201045
Report Date: 05/25/2022
Date Signed: 05/25/2022 12:49:47 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
05/18/2022 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20220518133714
FACILITY NAME:SG FACILITYFACILITY NUMBER:
079201045
ADMINISTRATOR:GRAN, SECINANDOFACILITY TYPE:
735
ADDRESS:990 JENSEN CIRCLETELEPHONE:
(925) 308-3316
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 1DATE:
05/25/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Secinando Gran, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident sustained an injury in care.
INVESTIGATION FINDINGS:
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On 5/25/2022 at 11:15AM, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings for the allegation above. LPA met with Secinando Gran, Administrator and explained the reason for the visit.

During the investigation LPA L. Hall interviewed staff and a witness. C1 no longer resides at the facility. LPA reviewed C1's file and obtained copies of facility roster, staff roster, admission agreement, IPP (Individual Program Plan), Behavior and Dangerous Propensities, discharge summary notes, health care checklist, incident report, and document of cancellation of contract.

During the investigation LPA interviewed S1 and S2. Both stated they did not know what

Continued on LIC9099.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
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 2
Control Number 15-AS-20220518133714
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: SG FACILITY
FACILITY NUMBER: 079201045
VISIT DATE: 05/25/2022
NARRATIVE
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Continued from LIC9099.

C1 bumped into to get the bruise. C1 was having behavior issues on 5/12/2022. C1 was walking fast and jumping around the facility. S1 stated C1 was given a bath on 5/13/2022 when bruise was observed and that W2 was notified. S1 stated bruise was approximately 1 inch in width. C1 didn't seem to be bothered by bruise. S1 stated he didn't feel bruise was bad enough to be seen by a doctor.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2