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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604481
Report Date: 07/07/2023
Date Signed: 07/07/2023 02:57:04 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2023 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20230615091600
FACILITY NAME:COLUMBIA RESIDENTIAL CARE LLCFACILITY NUMBER:
374604481
ADMINISTRATOR:CHANEL BERNARTEFACILITY TYPE:
735
ADDRESS:1610 COLUMBIA STREETTELEPHONE:
(858) 294-3670
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:4CENSUS: 3DATE:
07/07/2023
UNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:CHANEL BERNARTE AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff speak inappropriately to client.
Staff is harassing client.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Licensee Chanel Bernarte.

During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interview with staff, resident and outside sources.
It was alleged that staff speak inappropriately to client. LPA Domingo reviewed a statement from Client 1 (C1), (See LIC811 Confidential Names list), that stated staff speak to the client with respect and dignity. Review of C1's LIC602 Physician's report and LIC603 Pre-Placement Appraisal, there is documentation of C1's has a history of false accusations.

(Continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
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 08-AS-20230615091600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: COLUMBIA RESIDENTIAL CARE LLC
FACILITY NUMBER: 374604481
VISIT DATE: 07/07/2023
NARRATIVE
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Continued from LIC9099)

C1's false accusations are said when C1 has angry outburst due to unemployment or loss of a friendship. Interview with outside source 1 (OS1) observed staff treating residents with dignity. Interview with outside source 2 (OS2) has only observed staff treating residents with dignity and respect.

It was alleged that staff was harassing client. C1 verbalized and wrote a statement confirming that the staff has not harassed the client. C1 stated that there was a miscommunication with staff when C1 was upset. OS1 was interviewed and confirmed that there was no observation of staff harassing client.

Based on LPA's interviews with Client, outside source interviews, and records reviewed there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Licensee, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2