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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601233
Report Date: 12/08/2023
Date Signed: 12/08/2023 01:55:44 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
11/28/2023 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20231128162655
FACILITY NAME:BLESSING HOMEFACILITY NUMBER:
015601233
ADMINISTRATOR:GHITA, ZEPELINFACILITY TYPE:
740
ADDRESS:5195 PROCTOR ROADTELEPHONE:
(510) 909-2133
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:6CENSUS: 5DATE:
12/08/2023
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Zepelin Ghita, Adminstrator TIME COMPLETED:
02:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not treat resident with dignity.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/8/23 at 10:25 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct complaint investigation for the above allegations. LPA met with Licensee Elena Ghita and explained the purpose of the visit.

Allegation: Staff did not treat resident with dignity.

LPA interviewed R1, R2, R3, R4 and R5 regrading the above allegation. 5 out of 5 residents stated that staff all treated them with respected and dignity. R1 remembered the time that EMT brough R1 back S1 asked for instruction of care for R1 oxygen usage. R1 remembered EMT was being rude to S1 and was yelling at S1. LPA interviewed W1, and W1 stated that all the care that provided here at the facility is fantastic. W1 stated that staffs at this facility all treated residents with respect and dignity. Never had W1 heard any staff yelled at any resident while W1 is at the facility visiting W1 mother on the daily basic. W1 was in the room visiting W1 mom, and W1 heard that EMT was yelling and using curse word to S1. W1 was shocked of how unprofessional that this EMT is being.

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

Exit interview conducted and a copy of this report provided to Licensee via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
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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