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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200750
Report Date: 01/28/2026
Date Signed: 01/28/2026 04:26:53 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
10/27/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20251027095801
FACILITY NAME:SCOTT VILLAFACILITY NUMBER:
019200750
ADMINISTRATOR:JONABELLE TOLENTINOFACILITY TYPE:
740
ADDRESS:1560 MIDDLE LANETELEPHONE:
(510) 782-7833
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:35CENSUS: DATE:
01/28/2026
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Jonabelle Tolentino/AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not prevent residents from engaging in a physical altercation.
INVESTIGATION FINDINGS:
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On this day, January 28, 2026, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with Jonabelle Tolentino, administrator (ADM) and informed the purpose of visit.

The reporting party (RP) indicated that resident, R1, was attacked by another resident, R2, on October 22, 2025. RP further stated that it was reported that the incident was witnessed by residents and staff so RP thinks the incident happened in the common area.


.......continued on 9099C
Unsubstantiated
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 2
Control Number 15-AS-20251027095801
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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During the course of investigation, LPA obtained copies of resident roster and staff schedule. LPA reviewed residents' files and obtained copies of including but not limited to the following documents: LIC601 Identification and Emergency Information; LIC602A Physician's Report; LIC625 Appraisal/Needs and Services Plan. LPA interviewed the following: R1, staff (S1) and administrator (ADM) on October 30, 2025; R2 and R5 on January 28, 2026 and obtained additional information from ADM.

R1 stated the incident happened inside the facility in the hallway when R1 was going to the bathroom. During interview, LPA didn't observe any bruise in R1's face but scratches on left arm which R1 stated he scratched because his arm was itching. R2 stated R1 was messing up his coffee and his legs so he slapped R1's hand and it happened on the common area inside the facility. R2 was not able to provide the date nor names of staff or other residents who witnessed the incident. R5 stated the incident happened outside in the smoking area of the facility when R1 confronted another resident and R2 intervened. R5 futher stated that R2 turned around to R1 and flailed his hands toward R2 and R2 pushed and slapped R1 on the cheek. R5 stated the facility van arrived and the driver separated R1 and R2.

S1 stated not observing any incident between R1 and R2. ADM stated the van driver didn't report the incident. ADM further stated that R1 and R2 came to her on separate occasions regarding R1 staring at R2 and R2 spreading rumor about R1. ADM stated after the report, ADM transferred R1 and R2 to rooms far away from each other.

LPA reviewed the facility's camera footage for October 22, 2025 with ADM which covers the inside common areas. LPA didn't observed any incident between R1 and R2 on the alleged date. ADM indicated, and LPA observed the smoking area obstructed from the camera.

Based on information gathered, the allegation is unsubstantiated.A finding that the complaint 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: 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 2