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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011440861
Report Date: 08/15/2025
Date Signed: 08/15/2025 01:44:54 PM

Unsubstantiated


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
08/05/2025 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20250805115657
FACILITY NAME:B-N RESIDENTIAL CARE HOMEFACILITY NUMBER:
011440861
ADMINISTRATOR:BAUTISTA, ALEJANDRIA N.FACILITY TYPE:
740
ADDRESS:4801 MICHELLE WAYTELEPHONE:
(510) 471-6229
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
08/15/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Alejandria Bautista, Administrator AssistanceTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff restrained resident in care resulting in bruising to the resident
Staff did not seek medical attention for resident in care
Staff did not meet resident's hygiene care needs
INVESTIGATION FINDINGS:
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On 8/15/2025 at 8:45 am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to investigate the above allegations. LPA met with Alejandria Bautista, Assistant Administrator (AMD Assistance), and informed the reason for the visit. Alejandria has to leave and gave permission for Jovita Rivera, care staff to sign the report.

During the course of the investigation, LPA interviewed the resident (R) R1, 5 residents, LPA interview 4 staff members, interviewed administrator assistance, and interviewed R1's, W1, and W2. LPA reviewed residents' (R1s) records including but not limited to physician report, care notes, after visit summary and hospice notes.

Report contined on LIC 9009c...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
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-20250805115657
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: B-N RESIDENTIAL CARE HOME
FACILITY NUMBER: 011440861
VISIT DATE: 08/15/2025
NARRATIVE
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Allegation: Staff restrained resident in care resulting in bruising to the resident

Based on observation, interviews, and record reviewed, staff did not inappropriately restrain any resident while in care. W1 stated R1 came to the facility with a skin condition, due to taking a lot of medication that cause R1 skin to have discoloration. W2 stated R1 condition is not being restrained R1 condition is due to aging, and the medication that R1 takes.

Allegation: Staff did not seek medical attention for resident in care

Based on observation, interviews, and record reviewed, staff did seek medical attention for resident in care. W2 stated “when a person is on hospice, hospice they are responsible for any medical needs”. W2 stated the facility is good with updating the condition of R1 to W2. R1 is under hospice care, and they have a 24hr doctor that available to them.

Allegation: Staff did not meet resident's hygiene care needs

Based on observation and interviews staff did meet resident’s hygiene care needs. W1 stated the staff takes really good care of R1 hygiene. W2 stated “the staff met R1 hygiene needs and continence care. I don’t have any concerned with R1 hygiene. I am at the facility checking on R1 twice a week and I don’t have any concerned”.

Based on all information obtained, the allegations were closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there's not a preponderance of evidence to prove that the alleged violation occurred.

No deficiency cited. Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2