415600898-4-8-2025-14-AS-KHOS-DGMUM5-20250513154145

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600898
Report Date: 04/08/2025
Date Signed: 04/08/2025 02:58:20 PM

Unsubstantiated

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
02/06/2025 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20250206100807

FACILITY NAME:	OASIS DAY PROGRAM		FACILITY NUMBER:	415600898
ADMINISTRATOR:	MONTIEL, ALDO		FACILITY TYPE:	775
ADDRESS:	230 GRAND AVENUE		TELEPHONE:	(415) 407-6588
CITY:	SOUTH SAN FRANCISCO	STATE: CA	ZIP CODE:	94080
CAPACITY:	30	CENSUS: 29	DATE:	04/08/2025
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Linda Moreno & Maricela Guerra		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Clients are not accorded dignity and respect
Staff inappropriately restrained/secluded clients
Staff are not properly trained
Staff did not provide appropriate activities and engagement for client needs

INVESTIGATION FINDINGS:

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On 4/8/2025 LPA Grace Donato made an unannounced complaint investigation. LPA met with Program Supervisor, Linda Moreno & Lead Staff Maricela Guerra. LPA explained the purpose of the visit.

Regarding the allegations of clients are not accorded dignity and respect and staff inappropriately restrained/secluded clients, reporting party (RP) stated that on one occasion, RP witnessed two participants being confined to a small room. One participant was visibly agitated and half-dressed, while staff blocked the doorway without visible efforts at de-escalation. RP added that the staff physically held the client’s arms and/or wrist on more than one occasion and were blocking the door to keep two people in a room.

LPA interviewed PD and other staff members. During the interviews, PD mentioned that there is a quiet/relaxation room. Clients want to stay there if they just want to lie down or sit and cover their faces.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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 14-AS-20250206100807

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: OASIS DAY PROGRAM	FACILITY NUMBER: 415600898
	VISIT DATE: 04/08/2025

NARRATIVE

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The staff will just stand outside the door to observe and be on stand by if clients need anything. S2 also shared that if clients show behaviors they try to hold their hands and talk to them. By holding the clients hands carefully, they talk to clients slowly and tell them to calm down and to also prevent clients for hurting themselves. With regards to blocking the doorway, staff are there for the clients safety, for them not to run out on the street. For the client (R2), he/she is always half dressed coming from the home. That is part of the behavior.

Regarding the allegation of Staff are not properly trained, RP stated that the two assigned staff did not intervene, nor did the program’s crisis intervention trainer—who is also the administrator. This raises concerns about staff training, proactive intervention strategies, and overall supervision in the program. RP have observed what appears to be staff restraining R1 by his/her hands and escorting R1 by force. If staff are unable to anticipate and intervene appropriately in behavioral incidents, both participants and staff remain at risk. During one visit, a participant requiring two-to-one staffing struck RP in the head.

LPA interviewed S1, who is one of the staff assigned to R1. S1 shared that they are aware and knows what behaviors R1 has. In order to help de-escalate R1 when he/she is showing behaviors, S1 puts their arms under the armpits and assist the client to walk. S1 also mentioned that the person struck was not hit by an object but water coming from the beanie that R1 wore and was soaked. S1 mentioned that R1 has that behavior of flinging objects. PD also shared that RP was advised beforehand of the behavior of R1. S3 also shared that the behavior happened because RP had staff return R1 to the program when staff was trying to de-escalate the behavior by walking R1 around the area. R1 got more agitated when the staff returned back to the facility.

Based on records reviews, the resident (R1) has different behaviors such as spitting, vomiting, flinging/smearing of biohazardous materials.

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SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20250206100807

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: OASIS DAY PROGRAM	FACILITY NUMBER: 415600898
	VISIT DATE: 04/08/2025

NARRATIVE

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These behaviors have an outlined strategy on how staff would address them if it happened. Part of the strategies to de-escalate the behavior is to speak to R1 in a friendly and gentle tone, reinforce communication attempts, going on a walk, offering movement opportunities, access to preferred leisure toys and activities, use one-step directions that are known and can do (stop, sit down), provide R1 with tangible preferred items that will act as competing stimulus for flinging. Due to these types of behaviors, the staff are trained by PD who is a certified Professional Assault Crisis Trainer. The training includes workshops in Professional Assault Crisis Training with different focuses one of which is making restraint as last resort.

During the visit, it was also observed that R1 has 2 assigned staff. R1 has adjusted to the staff since he/she first started in the program.

For the allegation of Staff did not provide appropriate activities and engagement for client needs, RP reported that programming at the facility appears inconsistent and inadequate. Programming appears to only happen between 10:00 AM and 1:00 PM due to transportation to and from the program. Additionally, on multiple visits, upon entering the facility, only 2-3 participants were being engaged by staff. Nearly all participants were in the large room. While 1 or 2 may have been using an iPad, most of the other participants were sitting with no activities or materials.

RP also added that when asked about the inactivity, management frequently repeated, “We can’t force them to do anything, they have rights.” This suggests a lack of understanding that is hard to fathom in a program of this kind, where engagement and structured activities should be a fundamental component of service. During one of the visits, it was implied that participants were going on a bowling outing, but the outing never happened. When asked a participant about it, he/she said, “That rarely happens.” This raises concerns about whether outings and other scheduled activities are actually taking place or if they are being used as placeholders rather than meaningful opportunities for engagement.

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SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20250206100807

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: OASIS DAY PROGRAM	FACILITY NUMBER: 415600898
	VISIT DATE: 04/08/2025

NARRATIVE

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Additionally, observed activities appeared to be extremely limited. Participants were seen engaging in coloring, bowling, relaxing, watching TV, and exercising to a DVD, but there was little evidence of structured, individualized engagement or age-appropriate skill-building activities.

Based on interview with PD, there is a lot of activities that are offered. They go to a ranch in Half Moon Bay and they feed the horses with treats they made in the program. Go to Safeway and help bring carts back to the store, Community gardening in Orange park, go bowling, do Exercises, Zumba, bingo – which are done in the facility. They plan the activities specially the outing everyday since it will depend if a client wants to join or not. One of the clients (R2), has intrusive thoughts, autistic and doesn’t like noise, prefers quiet places where there are no kids and likes to do the community gardening. Some clients just prefer coloring or just be in the activity room and not join the group in the large room. Staff does not force clients to join activities. They ask first then if client doesn’t want to join then they let them be. Once the activities start they try and ask again. Some clients would join but some still won’t. There are clients who just walks around the block with staff. It really depends on what they want to do that day. Programs start at 9:30 and ends at 2. Sometimes it depends if there are traffic so some residents come in around 10. S2 also shared that there is a scheduled program of activities for the clients but on the day it depends what the clients want to do. There is a scheduled music therapy every Monday, Wednesday and Friday and outings everyday.

LPA was able to obtain a program activity schedule for March 2025 and photos of the activities that clients do in the program.

LPA also observed on several visits that some clients do participate in different activities and some just sits down in the activity area. There are also clients who stay in the rooms and do their own activity.

Based on interviews, records review and observations, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Report is reviewed and copy is provided.

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SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC9099 (FAS) - (06/04)

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