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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201044
Report Date: 10/23/2025
Date Signed: 10/23/2025 01:21:26 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
08/28/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250828144613
FACILITY NAME:DEER RIDGE COUNTRY VILLAFACILITY NUMBER:
079201044
ADMINISTRATOR:SALAZAR, HENRYFACILITY TYPE:
740
ADDRESS:419 DEL MONTE COURTTELEPHONE:
(925) 997-7354
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 4DATE:
10/23/2025
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Daniela Hernandez, Caregiver TIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Staff did not report resident’s incident to appropriate parties
Staff did not follow proper eviction procedures with resident in care
Staff did not ensure that a call button was readily available to resident in care
INVESTIGATION FINDINGS:
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On 10/23/2025 at 10:50AM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegations above. LPA met with Daniela Hernandez, Caregiver and explained the reason for the visit. Kimberly Whittle, House Manager, arrived at approximately 11:25AM, LPA explained purpose of visit.


During the investigation, LPAs interviewed complainant, staff, reviewed and obtained document records.


Continue on LIC9099C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
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-20250828144613
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DEER RIDGE COUNTRY VILLA
FACILITY NUMBER: 079201044
VISIT DATE: 10/23/2025
NARRATIVE
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Continued from LIC9099


Allegation: Staff did not report resident’s incident to appropriate parties
During the investigation, Interviews revealed, facility reported resident incidents to CCLD, facility called W1 and sent text messages of resident incidents. Record review revealed, facility has a text thread of R1’s incidents sent to W1, and incident reports (LIC624) sent to CCLD.


Allegation: Staff did not follow proper eviction procedures with resident in care
During the investigation, Interviews revealed facility advised W1 prior to the eviction, of R1 needing a higher level of care. Record review revealed, facility did follow proper eviction procedure and issued a 60-day eviction notice which was given to W1 on August 18, 2025.

Allegation: Staff did not ensure that a call button was readily available to resident in care
During investigation, Interviews revealed, facility and W1 had a verbal and written agreement of R1 having limited access to the call button due to R1 excessively pressing of the call button. Record review revealed, W1 asked facility via text messages to remove the call button from R1 due to excessive pressing of the call button.


Based upon the information obtained during investigation. The above allegations are 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.


Exit interview conducted and a copy of report was given to Kimberly.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2