019200735-1-26-2023-15-AS-KHOS-CP3NSN-20230215094324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200735
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:51:28 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
09/12/2022 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20220912135604

FACILITY NAME:	CALIFORNIA MENTOR - MALABAR HOME		FACILITY NUMBER:	019200735
ADMINISTRATOR:	JOSEPH FARRISH III		FACILITY TYPE:	740
ADDRESS:	4639 MALABAR AVE		TELEPHONE:	(909) 483-2505
CITY:	CASTRO VALLEY	STATE: CA	ZIP CODE:	94546
CAPACITY:	4	CENSUS: 4	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Joseph Gapasin, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
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5
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7
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9

Resident sustained injuries while in care.
Facility did not seek medical attention for resident.
Facility is not adequately staffed to meet the needs of the resident's.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 1/26/2023 at 11:40AM Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to deliver complaint finding for the above allegations. LPA met with Administrator, Joseph Gapasin and explained the purpose of the visit.

During the complaint investigation, LPA toured 4 resident's bedrooms, interviewed 2 staff, and attempted to interview 4 residents. Based on information obtained, R1 is self-inflicted and staff took preventative action to prevent R1 from sustaining future injuries. Staff seek medical attention on a timely matter. Facility have adequate staff after LPA reviewed staff payroll that correspond to staff’s schedule.
UNSUBSTANTIATED

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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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