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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200735
Report Date: 12/30/2021
Date Signed: 12/30/2021 05:03:50 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
02/22/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210222092730
FACILITY NAME:CALIFORNIA MENTOR - MALABAR HOMEFACILITY NUMBER:
019200735
ADMINISTRATOR:CHRISTINE CARVAJALFACILITY TYPE:
740
ADDRESS:4639 MALABAR AVETELEPHONE:
(909) 483-2505
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:4CENSUS: 4DATE:
12/30/2021
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Joseph Farrish III, administratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Insufficient staff to meet residents needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/30/21 at 4:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to deliver the findings of above allegation. LPA explained the purpose of the visit with administrator.

Allegation: Insufficient staff to meet residents needs
Investigation Finding: UNSUBSTANTIATED
Based on interviews and observations by Licensing Program Analyst (LPA) A. O’Hollaren on 03/03/21, LPA observed 4 caregivers and one administrator assisting 4 residents at the facility during visit. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
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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