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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601179
Report Date: 06/16/2026
Date Signed: 06/16/2026 11:58:26 AM

Unfounded


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
03/25/2026 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20260325151656
FACILITY NAME:C & C CAREHOMEFACILITY NUMBER:
415601179
ADMINISTRATOR:GUMBAN, ETHELFACILITY TYPE:
740
ADDRESS:657 ANGUS AVE EASTTELEPHONE:
(650) 228-3777
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 4DATE:
06/16/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Ethel GumbanTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff abandoned resident at hospital
INVESTIGATION FINDINGS:
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On June 16, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to delivery the complaint investigation outcome. LPA met with administrator, Ethel Gumban and LPA explained the purpose of today's visit.

Regarding allegation of - staff abandoned resident at the hospital, there was no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that resident #1 (R1) was admitted to the hospital on 3/20/2026 and the administrator did not allow R1 to return back to the facility over the weekend until the hospital bed was delivered on 3/23/2026.

As part of the investigation, LPA interviewed the administrator and reviewed documents.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
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-20260325151656
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: C & C CAREHOME
FACILITY NUMBER: 415601179
VISIT DATE: 06/16/2026
NARRATIVE
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The administrator denied the allegation, and stating that R1 was not a resident during R1's hospital stay. The administrator further stated that she visited the hospital, conducted a pre-placement assessment, and requested a hospital bed in preparing of R1's admission.

Based on the admission agreement that was signed by R1's responsible party, R1's admission date was 3/23/2026.

Based on interview, and record review, this allegation is deemed to be unfounded, as R1 was not a resident during R1's hospital stay. Therefore, the allegation of abandonment concerning R1 is not applicable.

Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2