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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600563
Report Date: 08/13/2025
Date Signed: 08/13/2025 01:31:44 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-20250805122017
FACILITY NAME:A - R RESIDENTIAL CARE HOME FOR ELDERLY #2FACILITY NUMBER:
015600563
ADMINISTRATOR:BAUTISTA, ROMULO S.FACILITY TYPE:
740
ADDRESS:32322 JEAN DRIVETELEPHONE:
(510) 324-4478
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
08/13/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Alejandria Bautista, Assistant Administrator TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff inappropriately restrained a resident while in care
INVESTIGATION FINDINGS:
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On 8/13/2025 at 11:30 am, Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo arrived unannounced to investigate the above allegation. LPAs met with Alejandria Bautista, Assistant Administrator, and informed the reason for the visit.

During the course of the investigation, LPAs interviewed the resident (R) R1, 2 residents, attempted to interview 3 residens, intervewed 2 staff members, interviewed administrator/licenseem, and interviewed R1's POA. LPAs reviewed residents' (R1s) records.


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

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
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-20250805122017
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: A - R RESIDENTIAL CARE HOME FOR ELDERLY #2
FACILITY NUMBER: 015600563
VISIT DATE: 08/13/2025
NARRATIVE
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Allegation: Staff inappropriately restrained a resident while in care.

Based on observation, interviews, and record reviewed, staff did not inappropriately restrain any resident while in care. Residents were observed to be free from unauthorized physical, mechanical, or chemical restraints. R1's stated "I like to put my foot on the couch. I am able to move around freely". 3 out of 3 residents stated staff are not restraining them and are freely to move.

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: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2