019200687-10-12-2022-15-AS-KHOS-CKBN7D-20221018101235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200687
Report Date: 10/12/2022
Date Signed: 10/12/2022 11:57:23 AM

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
10/21/2020 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20201021093831

FACILITY NAME:	EDEN ASSISTED LIVING		FACILITY NUMBER:	019200687
ADMINISTRATOR:	TET, SAMUEL		FACILITY TYPE:	740
ADDRESS:	18787 CARLTON AVE		TELEPHONE:	(510) 885-0557
CITY:	CASTRO VALLEY	STATE: CA	ZIP CODE:	94546
CAPACITY:	6	CENSUS: 5	DATE:	10/12/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Samuel Tet, Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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9

Facility staff failed to accord dignity to resident in care
Facility staff pulled resident's hair

INVESTIGATION FINDINGS:

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9
10
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12
13

On 10/12/2022 starting at 10:45 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct complaint investigation for the above allegation. LPA met with Samuel Tet, administrator and explained the purpose of the visit.

During the course of investigation, LPA obtained information, collected documents; staff roster, resident roster, R1’s physicians report, R1’s ISP and interviewed staff and witnesses.

Based on all information obtained, the allegation is UNSUBSTANTIATED. An unsubstantiated finding 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 a copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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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