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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600122
Report Date: 01/28/2025
Date Signed: 01/28/2025 10:20:41 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250107163629
FACILITY NAME:FHAR-HILLER STREET HOMEFACILITY NUMBER:
415600122
ADMINISTRATOR:PHIL SURDELFACILITY TYPE:
735
ADDRESS:803 HILLER STREETTELEPHONE:
(650) 508-0212
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:6CENSUS: 6DATE:
01/28/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:House Manager, Flordilita SilvaTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility did not report sexual abuse of staff to another staff member to licensing
INVESTIGATION FINDINGS:
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On January 28, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegation. LPA met with, House Manager, Flordilita Silva and explained the purpose of the visit.

Regarding the allegation, facility did not report sexual abuse of staff to another staff member to licensing, according to the reporting party, on January 17, 2024, Staff 1 (S1) sexually assaulted Staff 2 (S2) in the facility with the 6 clients present.

Based on interview conducted with the administrator, S2 reported this incident to him on 1/19/2024. Administrator indicated he was unaware that he needed to report this incident to CCLD as none of the clients were involved.

Based on interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with House Manager and a copy is provided with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
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 14-AS-20250107163629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FHAR-HILLER STREET HOME
FACILITY NUMBER: 415600122
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2025
Section Cited
CCR
80061(b)
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80061 Reporting Requirements: (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
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Administrator shall submit a plan in writing on how to ensure all incidents that occur at the facility are reported to CCLD.
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Based on interview conducted with the administrator, he was unaware that he needed to report an incident that occurred on 1/17/24 regarding S1 sexually assaulting S2 to CCLD as the clients were not involved with the incident
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2