019200750-1-28-2026-15-AS-BFOG-DR5TKQ-20260209134819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200750
Report Date: 01/28/2026
Date Signed: 01/28/2026 01:51:28 PM

Substantiated

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
01/27/2025 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20250127122838

FACILITY NAME:	SCOTT VILLA		FACILITY NUMBER:	019200750
ADMINISTRATOR:	JONABELLE TOLENTINO		FACILITY TYPE:	740
ADDRESS:	1560 MIDDLE LANE		TELEPHONE:	(510) 782-7833
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	35	CENSUS: 34	DATE:	01/28/2026
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Jonabelle Tolentino/Administrator		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Neglect/lack of supervision: resident (R1) sustained unexplained while in care.

INVESTIGATION FINDINGS:

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On this day, January 28, 2026, at 12:30 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Jonabelle Tolentino, administrator (ADM) and informed the reason for visit.

The reporting party (RP) stated that on January 20, 2025, the facility contacted the hospice agency to report that R1 had a minor scratch on the forehead. RP further stated that on January 21, 2025, hospice nurse discovered two centimeters cut on R1’s forehead and observed bruising around R1’s eyes.

During the course of investigation, the Department obtained copies of LIC9020 Register of Facility Clients/Residents, staff roster and LIC624 Unusual Incident Report concerning resident (R1).

....continued on 9099C (page 2)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

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 4

Control Number 15-AS-20250127122838

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: SCOTT VILLA	FACILITY NUMBER: 019200750
	VISIT DATE: 01/28/2026

NARRATIVE

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Page 2

Copies of including but not limited to R1’s following documents were also obtained: Admission Agreement; LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Pre-placement Appraisal; LIC9172 Functional Capability Assessment; LIC625 Appraisal/Needs and Services Plan; Unusual Incident Reports; facility notes; doctor's visit notes. Local law enforcement was also involved in the investigation and copy of police report was obtained and reviewed. The following were interviewed: hospice nurse (RN) on February 11, 2025; R1’s family member (FM) on February 11, 2025; R1’s roommate (R2) on June 5, 2025; staff (S1, S2, S3, S4) on June 5, 2025 and June 30, 2025.

Documents showed R1 was on hospice, has major neuro cognitive disorder, required full assistance, and was non-verbal. Pre-placement Appraisal indicated R1 needed special observation/night supervision.

RN confirmed RP’s statement that the facility called hospice agency on January 20, 2025, and that R1 had a cut on the forehead. RN further stated that RN came to visit on January 21, 2025, and the cut was deeper than what the facility described. The cut did not require hospitalization, but it was red and about two centimeters long, and there was bruising forming around R1’s eyes. RN asked the care staff for an explanation. The care staff believed the incident occurred around Sunday night, January 19, 2025, going into Monday morning, January 20, 2025, but the staff provided no specific time, or explanation for the cause of the unexplained injuries.

FM visited R1 at the facility on January 23, 2025 and was informed by the staff that R1 had a cut on forehead and two black eyes. The staff told FM that they think R1 did it to self but when FM saw R1’s condition, FM felt it was unlikely that R1 could have caused the injuries to thyself.

.....continued on 9099C (page 3)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20250127122838

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: SCOTT VILLA	FACILITY NUMBER: 019200750
	VISIT DATE: 01/28/2026

NARRATIVE

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Staff initially believed R1’s injuries were self-inflicted due to R1’s history of restlessness, and staff speculated that R1 may have rolled over and bumped self on the bed rails. R1’s roommate, R2, was also suspected by staff and by the local law enforcement of causing the injuries; however, R2 was interviewed by the Department and police officer and R2 denied any involvement and claimed not to have witnessed anything. Overnight shift staff are supposed to check on residents every one to two hours but based on law enforcement’s review of the facilities’ camera footage, no checks were made by care staff between 0325 to 0723 hours. Staff (S2) was seen entering R1 and R2’s room at 0544 with a broom and again at 0710 with tray of food, but the injury was not discovered until about 0723 hours. Two of the staff (S2 and S3) were inconsistent in their statements. S3 initially reported to the police that she cared for R1 the night of the incident and saw no injuries. However, S3 later recanted and admitted not on duty and later confirmed that it was S1 was the only staff working the overnight shift on the night of the incident. S1 was interviewed by the Department. S1 stated she conducted her rounds every hour during the overnight shift despite camera footage showing no checks were completed between 0325 to 0723 hours. Therefore, the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. A $500.00 immediate civil penalty is assessed and will continue for $100.00/day until corrected. An additional civil penalty may be assessed.

Deficiency, plan and proof of correction and civil penalty were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20250127122838

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: SCOTT VILLA	FACILITY NUMBER: 019200750
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/29/2026 Section Cited HSC 1569.269(a)(6)	1 2 3 4 5 6 7	§1569.269 Enumerated rights; severability: (a)Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency....	1 2 3 4 5 6 7	R1 is no longer at the facility. Administrator to in-service the staff and ensure proper care and supervision are provided to the residents in care. Copy of training topics with attendees signatures to be provided by 1/29/26.
	8 9 10 11 12 13 14	....to meet their needs. -This requirement is not met as evidence by: -Based on interviews and records review, the licensee did not comply with the section when R1 sustained injuries which posed an immediate health, safety and/or personal rights risks to person in care.	8 9 10 11 12 13 14	A $500.00 civil penalty is assessed.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

LIC9099 (FAS) - (06/04)

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