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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201097
Report Date: 02/28/2024
Date Signed: 02/28/2024 02:53:17 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
12/21/2023 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231221082023
FACILITY NAME:CASA ANDRES, INCFACILITY NUMBER:
079201097
ADMINISTRATOR:GIL MENDOZA, ROLANDOFACILITY TYPE:
735
ADDRESS:3908 BOULDER DRTELEPHONE:
(925) 978-4374
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: DATE:
02/28/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ursula Martinez, Direct Support ProfiessionalTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident sustained bruises by an unknown perpetrator
INVESTIGATION FINDINGS:
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On 2/28/2024XXXXXXX at 2:30pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Yalin Sanchez, House Manager, arrived at 2:45pm, and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff and a witness, obtained and reviewed records.

On the allegation of resident sustained bruises by an unknown perpetrator.
Responsible Party (RP) reported while speaking with Client 1 (C1’s) family member on December 19, 2023, that C1 sustained unexplained bruises on her body from the care home between the dates of November 8 to November 16, 2023. The family member stated C1 was asked how the bruises had gotten there and C1 stated she was pushed by someone at the home.

Continued on LIC9099c.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
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-20231221082023
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: CASA ANDRES, INC
FACILITY NUMBER: 079201097
VISIT DATE: 02/28/2024
NARRATIVE
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Continued from LIC9099.

During interview with Staff 1 (S1) it was stated that C1 did have bruises. S1 explained that C1 received the bruises from self-injurious behaviors and staff observed the bruises on November 6, 2023, when C1 was directed to shower. Staff immediately notified S1. S1 then scheduled an urgent doctor’s appointment for C1’s foot and bruises for November 8, 2023. S1 also contacted C1’s psychiatrist and conservator. LPA also interviewed a witness (W1) from C1’s day program. W1 stated that C1 was having behavioral problems even though a 1:1 was appointed.

During record review LPA reviewed incident reports dated November 7, 2023, November 13, 2023, and after visit summary from Sutter Health dated November 12, 2023. Incident report dated November 13, 2023, indicated that Antioch Police Department (APD) visited the facility investigating a call received from C1’s family, but did not leave a card or report number. S1 have not heard anything further from APD All three documents indicated that C1 had bruises, none of which was caused by another person. Review of C1’s Individual Service Plan (ISP) dated September 2023, indicated that C1’s self-injurious behaviors had increased. C1 no longer resided at the facility as of November 11, 2023.

Based on the investigations conducted the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2