<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200735
Report Date: 03/30/2022
Date Signed: 03/30/2022 05:17:58 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
12/09/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211209152709
FACILITY NAME:CALIFORNIA MENTOR - MALABAR HOMEFACILITY NUMBER:
019200735
ADMINISTRATOR:JOSEPH FARRISH IIIFACILITY TYPE:
740
ADDRESS:4639 MALABAR AVETELEPHONE:
(909) 483-2505
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:4CENSUS: 4DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Joseph Gapasin, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff engaged in inappropriate behaviors with resident
Resident sustained unexplained bruises while in care
Staff are mismanaging resident's medications
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/30/2022 at 1:20 PM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct complaint investigation for the above allegations. LPAs met with Administrator, Joseph Gapasin and explained the purpose of the visit.

During the course of the investigation, LPAs obtained information, collected documents, interviewed 5 staff and 2 witnesses.

Allegation: Staff engaged in inappropriate behaviors with resident

Based on interview with 5 staff, 5 of 5 denied sleeping on C1's bed or witnessed other staff sleeping on C1's bed. W2 stated W2 witnessed S5 resting on C1's bed.

REPORT CONTINUES ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
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-20211209152709
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: CALIFORNIA MENTOR - MALABAR HOME
FACILITY NUMBER: 019200735
VISIT DATE: 03/30/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
However, W2 was unable to produce proof of incident. LPA was unable to prove or disprove allegation.

Allegation: Resident sustained unexplained bruises while in care

According to W1, C1 has Self Injuries Behavior (SIB) where C1 hits his head and neck. 5 of 5 staff stated due to C1's vision impairment, C1 would often bump into walls and furniture which would cause the bruising.

Allegation: Staff are mismanaging resident's medications

Based on interview with 5 staff, 5 of 5 staff denied throwing medications away. LPAs reviewed a sample of clients medications and compared it with Medication Administration Record. LPAs did not observe any discrepancies. LPAs were unable to prove or disprove allegation.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2