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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201526
Report Date: 11/06/2025
Date Signed: 11/06/2025 02:18:15 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
10/30/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20251030104340
FACILITY NAME:EVELYN MANORFACILITY NUMBER:
019201526
ADMINISTRATOR:MONTECLAR, IRENEFACILITY TYPE:
740
ADDRESS:1076 TULANE AVETELEPHONE:
(650) 703-1217
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY:4CENSUS: 4DATE:
11/06/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Irene Monteclar, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff handled resident in an inappropriate manner
INVESTIGATION FINDINGS:
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On 11/06/25 at 1PM, Licensing Program Analysts (LPAs) D Panlilio and Y Brown conducted an unannounced complaint visit, met with staff (ADM, S1, S2, S3), gathered information on the complaint and delivered investigation finding to ADM.

During investigation, LPAs conducted interviews with staff (ADM, S1, S2. S3), clients (C1, C2, C3, C4) and obtained the following documents from administrator – Personnel record, Clients’ roster, admission agreements, physician’s reports, ISP/IPP plans, appraisals, needs & services plans, activities schedules, incident reports.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
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-20251030104340
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: EVELYN MANOR
FACILITY NUMBER: 019201526
VISIT DATE: 11/06/2025
NARRATIVE
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Allegation: Staff handled resident in an inappropriate manner
Finding: Unsubtantiated
During investigation, LPAs interviewed staff (ADM, S1, S2, S3), clients (C1, C2, C3, C4) and reviewed clients’ documents. Staff (ADM, S1, S2, S3) denied mishandling any client while in care. Review of clients (C1, C2, C3, C4) latest ISP/IPP plans dated 09/24/25 showed they are non-verbal and have profound intellectual disabilities. LPAs interviewed Ci1, C2, C3, C4 during visit. However, due to profound intellectual disabilities, LPAs were unable to confirm if staff physically or verbally abused them while in care. Staff stated they do not push or mishandle any client when travelling in or out of their transport vans during outings. On 11/06/25 at around 1:30PM, LPAs observed two male staff safely assist four non-verbal clients out of the transport van into the facility after a community outing.

On prior unannounced visits dated 10/01/25 and 11/06/25, LPAs did not observe staff mishandle any clients physically or verbally while exiting from the transport vehicle and returning back to the facility. ADM also stated staff continue to assist and redirect clients daily to help them achieve their care plan goals of being independent in performing their activities of daily living (ADLs) as well as being physically and socially active in the community.. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff handled resident in an inappropriate manner is unsubstantiated.

No deficiency cited during visit.



Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2