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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601459
Report Date: 08/17/2021
Date Signed: 08/17/2021 02:34:56 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/07/2021 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20210707113808
FACILITY NAME:BALTIC SEA MANORFACILITY NUMBER:
075601459
ADMINISTRATOR:PRICE, VIVIANFACILITY TYPE:
740
ADDRESS:311 BALTIC SEA COURTTELEPHONE:
(925) 783-0988
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 6DATE:
08/17/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Florin Jervoso, CaregiverTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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9
Staff sexually abused resident.

Staff pinched resident.
INVESTIGATION FINDINGS:
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On 8/17/2021 at 2:15PM, Licensing Program Analyst (LPA), L. Hall conducted and unannounced visit to deliver complaint findings for the above allegations. LPA met with Florin Jervoso, Caregiver and explained the purpose of the visit. LPA spoke with Administrator, Vivian Price via telephone. Administrator approved for Caregiver to sign document.

During the course of the investigation, the Department conducted interviews with residents, staff, obtained and reviewed resident’s records. Based on interviews and record review by the Department, there were no definitive facts or timeline to determine if R1 was sexually abused or hurt by facility staff. During R1’s interview she did not make any disclosures of sexual or physical abuse.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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 15-AS-20210707113808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BALTIC SEA MANOR
FACILITY NUMBER: 075601459
VISIT DATE: 08/17/2021
NARRATIVE
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Continued from LIC9099.

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

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2