397202945-5-16-2023-27-AS-LKIG-CS4M4N-20230523091701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397202945
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:17:10 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2023 and conducted by Evaluator Michael Bilger

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230420113531

FACILITY NAME:	CASA DE ORO		FACILITY NUMBER:	397202945
ADMINISTRATOR:	VAN DE POL, NELLEN		FACILITY TYPE:	735
ADDRESS:	6717 LORRAINE AVENUE		TELEPHONE:	(209) 957-3907
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95210
CAPACITY:	6	CENSUS: 6	DATE:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Jovencita Castillo		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Unknown perpetrator hit resident in care causing an injury
Unknown perpetrator yells at resident in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 5-16-23 at 2:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegations noted above. LPA met with lead caregiver Jovencita Castillo and explained the purpose of the visit. Administrator Nellen Van De Pol was not present and gave persmission for lead caregiver to accommodate LPA and sign in her absence. During this investigation, LPA interviewed 3 staff members and 6 residents in care. LPA also conducted facility observation on 4-21-23 and reviewed photographs submitted by an outside party. Additionally, LPA reviewed facility file documentation including physician report for resident1 (R1), R2, R3, R4, R5, an R6. Furthermore, LPA reviewed most recent resident council notes.
Allegation #1: Unknown perpetrator hit resident in care causing an injury. Based on interviews, observation, and record reviews, it was revealed that there were no corroborated witnessing statements expressing either staff hitting residents or residents hitting other residents in care. A review of resident council notes did not express concerns regarding residents being hit by others.
{Cont. on 9099C}

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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 27-AS-20230420113531

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CASA DE ORO	FACILITY NUMBER: 397202945
	VISIT DATE: 05/16/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Additionally, based on photo submitted and interview conducted, an injury to R1’s top of head was described as bruised and bleeding, however, cause was undetermined, and not stated through interviews as the result of being struck by any individual. Furthermore, photo reviewed did not reveal a clear visual of an injury and LPA did not observe bruising or bleeding to R1’s top of head during LPA’s visit on 4-21-23. LPA’s observation on 4-21-23 also did not reveal any instances of aggressive acts towards residents in care by staff or other residents on premises. As a result, there is not a preponderance of evidence to conclude that resident was hit by anyone causing an injury, therefore, this allegation is UNSUBSTANTIATED.

Allegation #2: Unknown perpetrator yells at resident in care. Based on interviews, observation, and record reviews, it was revealed that there were no corroborated witnessing statements expressing either staff yelling at residents or residents yelling at other residents in care. A review of resident council notes did not express concerns regarding residents being yelled at by others. A facility observation on 4-21-23 did not reveal any episodes of residents being yelled at by staff or other residents in care. As a result, there is not a preponderance of evidence to conclude that resident was yelled at by anyone therefore, this allegation is UNSUBSTANTIATED.

An exit interview was conducted with Jovencita Castillo and a copy of this report was provided to Jovencita. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2