415601091-12-20-2023-14-AS-KHOS-CZAKXT-20240108071803

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601091
Report Date: 12/20/2023
Date Signed: 12/20/2023 01:36:27 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
10/30/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231030114959

FACILITY NAME:	OAKMONT HOME 2		FACILITY NUMBER:	415601091
ADMINISTRATOR:	CHAN, JEVELYN		FACILITY TYPE:	735
ADDRESS:	2498 OAKMONT DRIVE		TELEPHONE:	(650) 580-3896
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	4	CENSUS: 3	DATE:	12/20/2023
		UNANNOUNCED	TIME BEGAN:	01:12 PM
MET WITH:	Administrator, Bill Fajardo		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff hit resident in care.

INVESTIGATION FINDINGS:

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On 12/20/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint investigation findings. LPA met with the administrator and explained the purpose of today's visit.

Regarding to allegation of staff hit resident in care, the reporting party stated that staff #1(S1) and staff #2 (S2) would often hit resident #1 (R1) when R1 gets agitated. However, the reporting party did not have any additional details.

As part of the investigation, LPA interviewed administrator, assistant administrator, facility staff and observed R1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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 14-AS-20231030114959

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OAKMONT HOME 2	FACILITY NUMBER: 415601091
	VISIT DATE: 12/20/2023

NARRATIVE

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According to the administrator and the assistant administrator, this alleged abuse incident was reported to them by a former staff who resigned without any notice and during the conversation, he/she mentioned that S1 hit R1 but did not said anything about S2. In addition, they stated that this former staff stated that there was a female staff who witnessed the incident but was not able to provide the name of this female staff and was not able to provide the date and/or time when this happened except for an approximation of the time frame.

After obtaining the above information, the facility's Licensed Vocational Nurse (LVN) conducted an assessment of R1 and it did not noted any injuries.

The administrator and the assistant administrator reviewed the assignment according to the time frame that was provided by this former staff and interviewed the facility staff who were working during that time including the female staff who the reporting party stated to witness the incident and all of them reported that they have not witnessed any staff hitting resident(s) in care.

LPA interviewed 6 facility staff and all of them reported that they have not witnessed anyone hitting, and slapping residents. However, one of them reported that he/she witnessed S1 put his/her hands on R1 to stop R1 from hitting. This reporting has been investigated, see LIC809 Case Management Report for details.

During the visit on 11/1/2023, LPA did not observed any injuries on R1.

Based on the documentation provided by the facility during time of the incident, there were no bruises, no discoloration, and no excoriation noted on R1.

Base on record review and interviews during the course of investigation, this allegation is unsubstantiated.

Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is reviewed and discussed with the administrator. A copy is provided.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

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