019200506-12-10-2021-15-AS-KHOS-C9VK6K-20211220063738

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200506
Report Date: 12/10/2021
Date Signed: 12/10/2021 01:57:07 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
05/21/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20200521144419

FACILITY NAME:	HERITAGE HAVEN		FACILITY NUMBER:	019200506
ADMINISTRATOR:	FERDINAND GUTIERREZ		FACILITY TYPE:	740
ADDRESS:	389 JUANA AVENUE		TELEPHONE:	(510) 357-1300
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	27	CENSUS: 19	DATE:	12/10/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Ferdinand Gutierrez/Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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-Resident smoking in non-designated smoking areas of facility.

-Staff not preventing resident from making inappropriate comments to another resident.

-Resident drinking liquor inside the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with Ferdinand Gutierrez, administrator, and informed the purpose of visit. LPA called Jene Snipes and informed the findings.

During the course of investigation, LPA obtained copies of the following: resident roster; staff schedule; House Rules; LIC601 Identification and Emergency Information; Physician's Report; LIC603 Preplacement Appraisal; LIC624 AppraIsal/Needs and Services Plan. LPA interviewed staff (S1, S2, administrator), licensee and residents (R1, R2 and R4).

.....continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

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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Control Number 15-AS-20200521144419

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: HERITAGE HAVEN	FACILITY NUMBER: 019200506
	VISIT DATE: 12/10/2021

NARRATIVE

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Allegation: Resident (R1) smoking in non-designated smoking areas of facility.

Facility House Rules includes "Smoking is only allowed in designated area." Staff interviewed indicated the facility has smoking areas outside the facility and no resident smokes inside. One out of 3 residents interviewed said R1 smokes inside the facility. R1 stated he smokes but denied smoking inside and that he smokes in designated smoking area. R4 stated not observing any residents smoking inside the facility,

Allegation: Staff not preventing resident (R1) from making inappropriate comments to another resident (R2).

Staff (S1 and S2) stated that residents yell at other residents which is their behavior; however, when they hear them, they check on them. When administrator is present, the administration breaks the altercation. R2 stated R1 made inappropriate comments to R1; however, R2 denied it. R4 indicated not hearing R1 making inappropriate comments to other residents. Administrator indicated that if resident yell or have altercation with other resident, he intervenes and take necessary actions.

Allegation: Resident drinking liquor inside the facility.

Facility House Rules includes "Drinking is strictly prohibited." R1 denied drinking inside the facility. S2 and R4 stated not observing other residents drinking inside the facility. S1 stated R3 has been drinking inside the facility. Although LPA observed empty cans of beer inside R3’s bedroom during inspection, the licensee indicated R3 had drinking problem when admitted and that they have worked closely with R3’s case manager regarding the behavior. Licensee stated R3 was sent out to rehab and didn’t return to the facility. LPA was unable to obtain information from R3 and R3’s case manager.

Based on information gathered, the allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

LIC9099 (FAS) - (06/04)

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