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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200737
Report Date: 12/20/2024
Date Signed: 12/20/2024 03:34:40 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
03/09/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220309160459
FACILITY NAME:CALIFORNIA MENTOR-MARINEVIEW HOMEFACILITY NUMBER:
019200737
ADMINISTRATOR:JOE FARRISHFACILITY TYPE:
740
ADDRESS:2420 MARINEVIEW DRIVETELEPHONE:
(916) 300-9510
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:4CENSUS: 3DATE:
12/20/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rosemary Maurillo/Area DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident was not supervised while on an outing with staff.
INVESTIGATION FINDINGS:
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On this day, 12/20/24, at 1:30 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Area Director Rosemary Maurillo and informed the purpose of visit. LPA called and spoke on the phone with Maehellena Harlan, administrator.

It was alleged that S1 took resident, R1, to a community outing on 3/08/22 and when they returned the other staff discovered a piece of paper with several transactions on it indicating that S1 had been doing DoorDash while R1 was with S1.



....continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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-20220309160459
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-MARINEVIEW HOME
FACILITY NUMBER: 019200737
VISIT DATE: 12/20/2024
NARRATIVE
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During the course of investigation, LPA obtained copies of staff schedule, lists of facility residents and staff, and reviewed residents' records. LPA obtained copies of residents' including but not limited to the following documents: LIC601 Identification and Emergency Information; LIC602A Physician's Report; Annual Review. LPA also obtained copy of Community Outings Record, LIC501 Personnel Record and LIC500 Personnel Report. LPA interviewed resident on 3/16/22 and staff (S1, S2, S3, S4, S5, S6 and interim administrator) on 3/16/22, 12/19/24 and 12/20/24.

S1 stated he could have drove the van and taken the resident out for community outings but denied the allegation and stated not working for DoorDash. Three of the staff stated not working on 3/08/22 while the other staff stated seeing the paper. Another staff also stated seeing the paper with S1's name on it but would not say it's a receipt but the paper appeared to be a computer print out. The interim administrator (ID) stated that the paper was given to her on 3/10/22 and that the paper does not have a letter head so she was not sure if it's a blank statement but it has S1's name, date and time, and DoorDash transaction in it. The ID stated she conducted an internal investigation and that S1 denied the allegation. The ID further stated it's unknown if S1 was just transferring money to S1's account.

LPA interviewed one resident who stated not knowing R1 and S1. Due to medical diagnosis, LPA was not able to obtain information from the other 3 residents.

Review of Community Outing showed R1 went for an outing on 3/08/22; however, the paper with DoorDash transaction was dated 3/04/22.

Based on information gathered and LPA unable to obtain information from 3 residents due to medical diagnosis, the allegation is closed a unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2