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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201128
Report Date: 09/24/2024
Date Signed: 09/24/2024 03:09:43 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
05/08/2024 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20240508081719
FACILITY NAME:NICOLE HOMEFACILITY NUMBER:
079201128
ADMINISTRATOR:FERNANDEZ, FERNANDO C.FACILITY TYPE:
735
ADDRESS:613 MARATHON DRIVETELEPHONE:
(510) 861-5810
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 3DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Fernando Fernandez, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Due to staff neglect, resident sustained bruising
INVESTIGATION FINDINGS:
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On 9/24/24 at 2:15 p.m., Licensing Program Analyst (LPAs) Greg Clark and Tonica Syess-Gibson arrived unannounced to deliver findings in regard to the allegation above. LPA met with Fernando Fernandez, Administrator and explained the purpose of the visit.

During the course of investigation, LPAs interviewed the reporting party (RP), the RCEB Care Manager (W1), R1 and facility staff. LPAs also reviewed R1’s file including the Special Incident Report (SIR) dated 5/8/24.

Interviews conducted and file review document R1 has a long history of self-abusive behavior (SIB).

***reports continues on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
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-20240508081719
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: NICOLE HOME
FACILITY NUMBER: 079201128
VISIT DATE: 09/24/2024
NARRATIVE
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***report continues from LIC9099***

R1 was hospitalized on a 5150 at Contra Costa Regional Medical Center from 5/07/24 to 6/06/24 when the facility called 911 due to R1 being aggressive to staff and engaging in SIB (scratching her skin, punching her legs, arms, and other body parts). S1 reports that R1 engages in SIB 2- 3 times daily.

LPAs observed R1 at the facility sitting in a recliner watching a movie. R1 smiled and nodded when LPAs asked her questions. LPAs did not observe any bruises on R1. R1 did not engage in any SIB during the visit.

This agency has investigated the complaint alleging due to staff neglect, resident sustained bruising. We have found that the complaint was unsubstantiated. 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, a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2