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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601499
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:48:16 PM

Substantiated


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
05/23/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230523113154
FACILITY NAME:A NEW HAVEN CARE HOME - BERLINFACILITY NUMBER:
015601499
ADMINISTRATOR:ROBERT ABELLAFACILITY TYPE:
740
ADDRESS:1422 BERLIN WAYTELEPHONE:
(925) 784-3842
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 5DATE:
09/27/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Roberto 'Robert' Abella/Administrator TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff did not follow reporting requirements.
INVESTIGATION FINDINGS:
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On this day, September 27, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Administrator (ADM) Roberto 'Robert' Abella. LPA called and spoke with Arnold Soleta, licensee, over the phone, and informed the reason for visit.

During the course of investigation, the Department obtained copies of LIC501 Staff Records and resident’s LIC601 Identification and Emergency Contact Information, Facility Notes and Unusual Incident Reports (UIRs). Local law enforcement was also involved in the investigation and copy of Police Report was obtained.

The Department conducted interviews on 5/24/23, 5/25/23, 6/02/23, 2/12/24 and 2/13/24. The following were interviewed: licensee; staff (S1 and S2); family members (FM1 and FM2); witnesses (SS and W1). UIRs were reviewed.

..continued 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
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 5
Control Number 15-AS-20230523113154
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 NEW HAVEN CARE HOME - BERLIN
FACILITY NUMBER: 015601499
VISIT DATE: 09/27/2024
NARRATIVE
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Staff indicated the alleged abuse happened on first week of May 2023; however, licensee submitted the UIR on 5/23/23 with incident date 5/06/23. Police report showed the alleged abuse was reported by third party not by the licensee and there’s no evidence that the licensee reported the alleged abuse to law enforcement.

R1 sustained bruises which were observed by R1’s family member (FM2) and witness (SS) on May 1, 2023. W1 also confirmed observing the bruises which resulted from R1’s falling when being assisted in the bathroom. FM2 stated S2 informed him of the fall incident but S2 did not inform him of the bruises on R1’s chest area and shoulder. FM1 indicated he was informed by the facility staff about the fall incident which the Department confirmed with S2. Review of records and UIRs didn’t show the fall incident was reported to Community Care Licensing.

Based on information gathered, the preponderance of evidence has been met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with licensee over the phone in the presence of ADM.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230523113154
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 NEW HAVEN CARE HOME - BERLIN
FACILITY NUMBER: 015601499
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2024
Section Cited
CCR
87211(c)
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87211 Reporting Requirements
(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency.....
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R1 is no longer at the facility.

Licensee and administrator to read the Regulations and submit self-certification by 10/11/24
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... within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).

-This requirement is not met as evidenced by:
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Type B
10/11/2024
Section Cited
CCR
0000
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CONTINUED BELOW:
-Based on records review and interviews, the licensee did not comply with the section above in not reporting the incident and not reporting timely the alleged abuse which posed a potential safety and personal rights risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
05/23/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230523113154

FACILITY NAME:A NEW HAVEN CARE HOME - BERLINFACILITY NUMBER:
015601499
ADMINISTRATOR:ROBERT ABELLAFACILITY TYPE:
740
ADDRESS:1422 BERLIN WAYTELEPHONE:
(925) 784-3842
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 5DATE:
09/27/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Roberto 'Robert' Abella/Administrator TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Facility staff member (S1) sexually assaulted resident (R1) while in care.
INVESTIGATION FINDINGS:
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On this day, September 27, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Administrator (ADM) Roberto 'Robert' Abella. LPA called and spoke with Arnold Soleta, licensee, over the phone, and informed the reason for visit.

During the course of investigation, the Department obtained copies of LIC9020 Register of Facility Clients/Residents and staff schedule. The Department also obtained copies of LIC501 Staff Records and the following residents' records: Admission Agreement; LIC601 Identification and Emergency Information; LIC602A Physician's Report; LIC625 Appraisal/Needs and Services Plan; Facility Notes; Unusual Incident Report (UIR). Local law enforcement was also involved in the investigation and copy of Police Report was obtained.

.....continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230523113154
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 NEW HAVEN CARE HOME - BERLIN
FACILITY NUMBER: 015601499
VISIT DATE: 09/27/2024
NARRATIVE
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The Department interviewed staff members and licensee on 6/05/23 and 621/23, residents (R1, R2, R3 and R4) on 6/05/23, and R1’s family members (FM1, FM2) and friend (W1) on 5/31/23 and 6/02/23.

Although R1’s statement about S1 touching R1’s breast was consistent, details pertaining to when the touching occurred, frequency and statements made were inconsistent. S1 never provided 1:1 care to R1 and only assisted when another caregiver requested S1’s help in lifting and transferring R1, and S1 was never left alone with R1. It was reported that the incident occurred on or around 5/6/23, and S1 was not scheduled to work at the facility that day, but S1 does reside in the facility.

Because of R1’s diagnosis of Multiple Sclerosis (MS), staff used a “bear hug” technique to lift R1 from the front to prevent them from losing balance and falling over if done from behind. R1’s family member (FM1) and staff stated R1 was a heavyset woman with large breasts. It was possible that whoever transfers R1 could inadvertently touch R1’s breast. FM2 stated when he visited R1 at the facility, R1 reported to him the alleged abuse which took place on May 6, 2023. W1 stated R1 told W1 that when R1 was in bed, S1 entered R1’s room and placed his hand on R1’s right breast and squeezed it. S1 adamantly denied touching R1 inappropriately.

Other female residents (R2, R3 and R4) were interviewed, and they denied S1 helped them and denied S1 touching them. None of the staff or other residents witnessed inappropriate touching of R1.

Based on information obtained, there is not a preponderance of evidence to prove that the alleged violation occurred or did not occur, therefore, the allegation is unsubstantiated.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5