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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201175
Report Date: 12/13/2023
Date Signed: 12/13/2023 09:58:46 AM

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
09/25/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230925151651
FACILITY NAME:WINDERMERE AT WHITMANFACILITY NUMBER:
079201175
ADMINISTRATOR:WARD, WHITNEYFACILITY TYPE:
740
ADDRESS:1921 WHITMAN RD.TELEPHONE:
(415) 710-5169
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 4DATE:
12/13/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Cydel Caplo, StaffTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained bruising while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/13/2023 at approximately 9:25 am Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA met with caregiver Cydel Caplo and explained the purpose of the visit. Administrator Matt Ward was called and designated Cydel Caplo to sign off on the report.

During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents. It was documented in Resident 1 (R1) physicians report that R1 was on medication that caused her to bruise easily.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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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