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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201064
Report Date: 03/10/2026
Date Signed: 03/10/2026 06:03:33 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
03/05/2026 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20260305153330
FACILITY NAME:AMBER CARE HOMEFACILITY NUMBER:
079201064
ADMINISTRATOR:BULLARD, CLEARNISEFACILITY TYPE:
740
ADDRESS:3744 PINTAIL DR.TELEPHONE:
(925) 706-9922
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 3DATE:
03/10/2026
UNANNOUNCEDTIME BEGAN:
03:56 PM
MET WITH:Amy Burton, Licensee
Annie Del Rosario, Adminstrator		TIME COMPLETED:
07:30 PM
ALLEGATION(S):
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Facility staff is financially abusing resident
INVESTIGATION FINDINGS:
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On 03/10/26 at 4PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint investigation, met with administrator (ADM) and explained the purpose of the visit. LPA conducted staff )S1, S2) interviews, gathered information and delivered investigation finding to ADM.

During investigation, LPA interviewed reporting party (RP), staff (Licensee, ADM) and obtained and reviewed the following documents from ADM: Personnel record (LIC500), Resident roster(LIC9020), R1's appraisal report, physician's report, admission agreement, needs & services plan, after visit discharge reports, incident report, payment records.

Continued on next page, LIC9099-C




Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
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-20260305153330
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: AMBER CARE HOME
FACILITY NUMBER: 079201064
VISIT DATE: 03/10/2026
NARRATIVE
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At 4:10PM, LPA interviewed staff (S1) who stated that the resident (R1) was first admitted at the facility on 12/21/24. Review of R1's admission agreement dated 12/22/24 showed R1 was her own responsible party (POA) and paid for her monthly basic services and requested cash advances with her personal checks from 12/21/24 until 01/16/26.

Review of R1's personal checks issued from 12/22/24 to 01/16/26 showed R1 paid for the facility's monthly basic services and requested cash advances from the administrator to purchase personal items such as Coloplast (Skin cream), diapers, underpads and favorite snacks (chips, sunflower seeds). LC also stated that R1 issued personal checks to pay for her primary residence's home association fees (HOA). LC and ADM denied financially abusing R1. ADM stated R1 was sent to the hospital on 02/03/26 for a change in condition. R1 returned back to the facility from the hospital on 02/20/26 under hospice care. R1 passed away on 02/28/26 and family collected her personal belongings on 03/01/26.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that facility staff was financially abusing resident is UNSUBSTANTIATED.

No deficiency cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2