019200750-5-5-2023-15-AS-BFOG-CRVSCX-20230516134615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200750
Report Date: 05/05/2023
Date Signed: 05/05/2023 07:09:55 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
02/07/2023 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20230207151023

FACILITY NAME:	SCOTT VILLA		FACILITY NUMBER:	019200750
ADMINISTRATOR:	JONABELLE TOLENTINO		FACILITY TYPE:	740
ADDRESS:	1560 MIDDLE LANE		TELEPHONE:	(510) 782-7833
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	35	CENSUS: 35	DATE:	05/05/2023
		UNANNOUNCED	TIME BEGAN:	06:45 PM
MET WITH:	Jonabelle Tolentino/Administrator		TIME COMPLETED:	07:15 PM

ALLEGATION(S):

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Facility staff interfering with personal telephone calls

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings on the above allegation. LPA met with Jonabelle Tolentino, administrator, and informed the purpose visit.

It was alleged that facility staff interfering with personal telephone calls. The reporting party (RP) and RRP stated that RP has repeatedly called the facility to speak with R1, and the facility is not allowing the phone calls or are interrupting the calls and hanging up the phone.

During the course of investigation, LPA obtained copies of LIC9020A Register of Facility Residents, reviewed resident's records and obtained copies of documents. LPA interviewed residents (R1, R2 and R3), statf (S1 and S2) and R1’s family members (FM1 and FM2).

.....continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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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Control Number 15-AS-20230207151023

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: SCOTT VILLA	FACILITY NUMBER: 019200750
	VISIT DATE: 05/05/2023

NARRATIVE

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R1 acknowledgedm and stated she knows RP and RRP, but indicated she has to stay away from them. R2 stated the staff allow him to receive and make phone calls using the facility telephone, while R3 indicated he does not want to make phone calls.

R1’s family members (FM1 and FM2) stated they gave instruction to the facility not to give the phone to R1 when RP amd RRP call because of the alleged abuse and that an investigation is still on-going for the complaint they filled to another agency for the abuse. Information was received by LPA from the said agency. S1 confirmed FM1 and FM2 statements that the facility was told not to give the phone to R1 when RP called. S2 indicated that she didn’t give the phone and hung up when RP called the facility.

Based on the information gathered, and R1’s family members and facility's intent to protect R1, and R1's statement she has to stay from RP and RRP, the allegation is closed as 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.

No deficiency cited.

Exit interview conducted and copy of this report provided to the administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC9099 (FAS) - (06/04)

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