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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601107
Report Date: 04/08/2022
Date Signed: 04/08/2022 01:16:49 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/24/2022 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220224162459
FACILITY NAME:BAY LEAF ELDERLY CARE HOME LLCFACILITY NUMBER:
415601107
ADMINISTRATOR:AVENA, MAYEANNE GUINOMMAFACILITY TYPE:
740
ADDRESS:1168 LYONS STREETTELEPHONE:
(650) 542-1692
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 5DATE:
04/08/2022
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Mayanne AvenaTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Lack of supervision resulting in resident's engaging in an altercation
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day at 1255hours, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the allegations recieved. LPA met with administrator Mayanne Avena and explained purpose of today's visit.

During the course of the investigation LPA conducted interviews and reviewed documents regarding R1 and the allegations recevied. It is discovered that R1 did get into verbal arguments with multiple residents over some time but staff were always staff present to mediate or re-direct. There was no physical altercations. There were verbal disagreements among residents and staff. This allegation is unfounded.

This agency has investigated the complaint alleging lack of supervision resulting in resident's engaging in an altercation . We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Report discussed with administrator.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/24/2022 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220224162459

FACILITY NAME:BAY LEAF ELDERLY CARE HOME LLCFACILITY NUMBER:
415601107
ADMINISTRATOR:AVENA, MAYEANNE GUINOMMAFACILITY TYPE:
740
ADDRESS:1168 LYONS STREETTELEPHONE:
(650) 542-1692
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 5DATE:
04/08/2022
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Mayanne AvenaTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Resident is being sexually abused while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Regarding the allegation of the resident being sexually abused while in care, it was discovered that the resident has made similar allegations in the past at other facilities she had resided in. Additional interviews witht he resident also showed that there was variances regarding the allegation. LPA was provided with a different answer than what was provided to other mandated reporting parties.

During the course of the investigation LPA conducted interviews and reviewed documents regarding R1 and the allegations. It cannot be determined if sexual abuse occurred while in care. There is no substantative information or medical findings indicating this. Interviews could not conclude if this even happened while in care at the faciilty. It was also found through interviews that different anwers were provided by the resident regarding this allegation and or that the resident could not recall if this had actually happend. This allegation is unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
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 above allegations are unsubstantiated at this time.

Report discussed with administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2