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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600350
Report Date: 12/29/2023
Date Signed: 12/29/2023 11:48:08 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/14/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230814121153
FACILITY NAME:GONZALES HOMEFACILITY NUMBER:
385600350
ADMINISTRATOR:GONZALES, ROGELIO & PROSPEFACILITY TYPE:
740
ADDRESS:2237 NORIEGA STREETTELEPHONE:
(415) 242-0848
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:6CENSUS: 4DATE:
12/29/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Caregiver Arotida "Ruth" YapTIME COMPLETED:
11:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff caused bruising to resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings in regards to the allegations referenced above. LPA met with carfegiver Ruth Yap and explained the purpose of today's visit.

During the course of the investigation, LPA conducted interviews, made observations of R1, and reviewed resident documents from the facility. The interview with R1 indicated a possible male in the room watching while S1 was in the room with R1. Interview with S1 says the bruising was not intentional as S1 was trying to assist R1 and remove R1's hands from the clothing of S1 as R1 was grabbing and being combative. R1 says it was someone they have never seen. According to interviews with staff, S1 was a long time staff person so it is not possible it was a person that R1 has never seen as S1 had assisted R1 many times. Additionally the male person that was alleged in the room was said to be the brother of S1 according to R1, but that is also not possible according to interviews. It was suggested that is was possibly another male staff member S2. Interivew with S2 resulted in that he was not working on the day this supposedly took place. There is not enough perponderance of evidence to show that the bruising was caused by S1 and in the manner in which it happened and who was present in the room of R1. The bed of R1 does have half bed rail for mobility reasons and possibly may have hit the half bed rail. This allegation is unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with Ruth Yap.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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