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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601347
Report Date: 10/12/2022
Date Signed: 10/12/2022 01:55:33 PM

Substantiated


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
10/06/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20221006160023
FACILITY NAME:C & L HOME FOR THE ELDERLYFACILITY NUMBER:
015601347
ADMINISTRATOR:GUZMAN, JOSELITO A.FACILITY TYPE:
740
ADDRESS:2660 HOP RANCH ROADTELEPHONE:
(510) 731-7743
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
10/12/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Vincent Catequista, StaffTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Facility did not fix clothes dryer
INVESTIGATION FINDINGS:
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On 10/12/2022 at 10:45AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct complaint investigation for the above allegation. LPA met with S2, LPA explained the purpose of the visit. LPA asked S2 to call Administrator (S1), S1 stated that he is not available during the visit.

Allegation: Facility did not fix clothes dryer
Based on LPA’s interview and observation, facility dryer is nonfunctional for about a month now. Based on interview Administrator is aware of the situation. Staff are hanging clothes at the backyard to air dry.

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
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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Control Number 15-AS-20221006160023
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: C & L HOME FOR THE ELDERLY
FACILITY NUMBER: 015601347
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited
CCR
87303(a)(1)
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Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include…. (1) Floor surfaces in bath, laundry…..
This requirement is not met as evidenced by:
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Administrator stated he already ordered parts of the dryer from Amazon, Adminsitrator stated that order will arrived today and he will replace the part of the broken machine. LPA requested from Administrator to submitted proof of receipt to be submitted by POC date.
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Based on observation and interview, Licensee failed to maintain an operational dryer so that clothes would not have to be dried on a rope in the back yard which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3