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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200735
Report Date: 01/12/2023
Date Signed: 01/12/2023 03:40:50 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
08/05/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20210805161616
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:
01/12/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joseph Gapasin TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff is rough with the resident.
Staff has inappropriate interactions with residents assistant in front of the resident.
Staff behavior is a health and safety risk to residents in care.
INVESTIGATION FINDINGS:
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On 01/12/2023, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver findings for the above allegations. LPA met with Administrator Joseph Gapasin and informed him the purpose of the visit.

During the course of investigation, LPA conducted records review and interview. Based on records review there was no incident report regarding R1 being handled in rough manner, R1 also do not have incident report of any type of bruising. Based on staff interview, they are not aware of any staff handling anyone roughly. Staff stated that they have not witnessed or heard any staff acting inappropriate behavior towards residents in care. LPA attempted to interview R1, but R1 is non-verbal, LPA also attempted to interview other residents, but residents did not answer LPA’s questions.

...Continue to LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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-20210805161616
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: 01/12/2023
NARRATIVE
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LPA observed during the visit that residents are comfortable, well dressed and staff are attending to each resident.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conduct and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2