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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200734
Report Date: 09/17/2025
Date Signed: 09/17/2025 01:06:59 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
09/05/2025 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20250905154629
FACILITY NAME:BAY CARE ASSISTED LIVING LLCFACILITY NUMBER:
079200734
ADMINISTRATOR:ONYEAGOCHA, ROSE CFACILITY TYPE:
740
ADDRESS:2352 SHANNON AVETELEPHONE:
(510) 964-1669
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:6CENSUS: 5DATE:
09/17/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:EVELYN PINON, CAREGIVERTIME COMPLETED:
01:23 PM
ALLEGATION(S):
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Staff does not ensure facility has adequate food supply.
INVESTIGATION FINDINGS:
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On 9/18/2025 at 12:15PM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge arrived unannounced to deliver complaint findings for the allegation above. Upon arrival, LPA met with Caregiver, Evelyn Pinon and explained to her the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff and witnesses. The Department obtained and reviewed the following documents: Personnel report, Residents' Roster, and menu.

CONTINUE ON LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
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 5
Control Number 15-AS-20250905154629
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: BAY CARE ASSISTED LIVING LLC
FACILITY NUMBER: 079200734
VISIT DATE: 09/17/2025
NARRATIVE
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CONTINUE LIC9099

Allegation: Staff does not ensure facility has adequate food supply.

Investigation Finding: Substantiated

W1 reported that the facility does not have an adequate food supply for the amount of residents. LPA conducted a tour of the kitchen and observed that the facility dose not meet the minimum of one week nonperishable food supply and two day of perishable food supply which should be maintained at the facility. Therefore, this allegation is Substantiated.

Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.




Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
09/05/2025 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20250905154629

FACILITY NAME:BAY CARE ASSISTED LIVING LLCFACILITY NUMBER:
079200734
ADMINISTRATOR:ONYEAGOCHA, ROSE CFACILITY TYPE:
740
ADDRESS:2352 SHANNON AVETELEPHONE:
(510) 964-1669
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:6CENSUS: 5DATE:
09/17/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:EVELYN PINON, CAREGIVERTIME COMPLETED:
01:23 PM
ALLEGATION(S):
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Resident sustained unexplained bruises while in care.

Staff yell at residents.
INVESTIGATION FINDINGS:
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On 9/18/2025 at 12:15PM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with Caregiver, Evelyn Pinon and explained to her the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff and witnesses. The Department obtained and reviewed the following documents: Personnel report, Residents' Roster, and menu.

CONTINUE ON LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250905154629
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: BAY CARE ASSISTED LIVING LLC
FACILITY NUMBER: 079200734
VISIT DATE: 09/17/2025
NARRATIVE
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CONTINUE FROM LIC 9099

Allegation: Resident sustained unexplained bruises while in care.

Investigation Finding: unsubstantiated

W1 reported that R1 had unexplained bruises, interview with S1 revealed that R1 has a habit of hitting the walls in R1s room when R1 is read to get out of bed which has caused the bruises on R1s arms. Interview with W2 revealed that due to R1 being on the heavier side the bruises could have come from R1 mobility such as getting up from bed or a fall. S2 was unsure of where the bruises came from. Therefore, this allegation is unsubstantiated.

Allegation: Staff yell at residents.

Investigation Finding: unsubstantiated

W1 reported that facility staff have been yelling at residents in care. Interview with W2 revealed that W2 has never witnessed staff yelling at residents. Interview with R2 revealed that staff have not yelled at R2 and R2 has never witnessed staff yelling at other residents in care. Interview with R3 revealed that R3 and the Administrator had a misunderstanding which caused R3 to raise R3’s voice and Administrator raised her voice at R3, R3 also stated that once R3 understood the situation that everything was fine and the facility takes good care of R3. R3 stated that R3 has not heard any staff yelling at any residents. Interview with R4 revealed that R4 has never been yelled at by staff and has not witnessed staff yelling at the residents. Interview with S1 revealed that S1 has not yelled at any of the residents but has spoken loud due to hearing issues of residents. Interview with S2 revealed that S2 has not yelled at residents, Therefore, this allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20250905154629
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: BAY CARE ASSISTED LIVING LLC
FACILITY NUMBER: 079200734
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2025
Section Cited
CCR
85076(d)(1)
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(d) The licensee shall meet the following food supply and...requirements:
(1) Supplies of staple nonperishable foods for a minimum... and fresh perishable foods for a ... premises. This requirement is not met as evidenced by:
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Administrator to purchase a minimum of one week nonperishable foods and a minimum of
Administrator shall also provide in- service training to all staff using an approved CCLD vendor on food service in compliance with Title 22 Section regulations, and submit a copy of all staff that attended training.
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Based on observation, the licensee did not comply with the section cited above in having an insufficient amount of perishables and non- perishable foods which poses a potential health and safety risk to persons in care.
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two days fresh perishable foods for facility and submit a copy of food and the receipt to CCL by POC due date. Administrator shall also provide in- service training to all staff using an approved CCLD vendor on food service in compliance with Title 22 Section regulations, and submit a copy of all staff that attended training.
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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: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5