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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803614
Report Date: 07/20/2023
Date Signed: 07/20/2023 10:14:30 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20230706122209
FACILITY NAME:OAKWOOD MEMORY & SENIOR CAREFACILITY NUMBER:
486803614
ADMINISTRATOR:MAHAWAR, RASHMIKAFACILITY TYPE:
740
ADDRESS:1025 OAKWOOD AVENUETELEPHONE:
(707) 643-0473
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:30CENSUS: 16DATE:
07/20/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:TJ IlaganTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident reported Physical Abuse while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with TJ Ilagan and discussed the disposition. Complainant has alleged that R1 stated that a staff person (S1) physically attacked R1 over a 3 day period. The resulting investigation has included a review of pertinent documents and taking of statements from witnesses and involved parties. The following determinations are made: R1 has a medical diagnosis that makes R1's testimony unreliable; Staff who were present at the time of the 7/2/23 incident recall R1 in an agitated state, throwing furniture and destroying facility property; S1 held R1 in order to avoid injury to other residents and to R1until assistance arrived; During a subsequent interview, R1 stated that S1 did not hit R1 but did restrain R1 and did not report any other incidents of alleged physical abuse. Although the allegation may be valid or true, based on the documents reviewed and the statements taken, there is not a preponderance of evidence to prove the allegation is or, is not, true. Therefore, the allegation is UNSUBSTANTIATED.
No citations issued today.
Report left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
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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