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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 176801307
Report Date: 08/08/2024
Date Signed: 08/08/2024 01:20:18 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20240725130851
FACILITY NAME:MANZANITA HOUSEFACILITY NUMBER:
176801307
ADMINISTRATOR:MARIAH UDENFACILITY TYPE:
735
ADDRESS:3997 MANZANITA DRIVETELEPHONE:
(707) 274-9293
CITY:NICESTATE: CAZIP CODE:
95464
CAPACITY:6CENSUS: 5DATE:
08/08/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mariah Uden, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff does not ensure facility is clean, safe and sanitary
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Mariah Uden, Administrator.

During the course of this investigation LPA conducted interviews, made observations, and obtained documents.
Staff does not ensure facility is clean, safe and sanitary - Complainant alleges staff does not ensure facility porch is free of tripping hazards due to extension cord running over the porch. LPA conducted visit of facility on 8/1/2024 and although pictures submitted with complaint show electrical cord on porch, extension cord was observed to not be on the porch but on the right side of the steps, coiled up on the ground. Complainant also alleges, staff does not ensure bathroom is free of mold & brown water in toilets. LPA observed during visit toilet to be clean, although observed what appears to be mold in the shower and bathroom ceiling (see pics). Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
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 21-AS-20240725130851
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MANZANITA HOUSE
FACILITY NUMBER: 176801307
VISIT DATE: 08/08/2024
NARRATIVE
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Continued from LIC9099

Complainant also alleges staff does not ensure resident's bedroom is free of mess as beds for two residents were messy to the point one could not see or navigate the floor. LPA observed client shared room in disarray with personal belongings scattered all over the room (see pics). It is also alleged facility carpets are dirty “stained & dark”, when LPA initiated visit client was vacuuming. LPA was informed by Administrator; clients have the options of doing chores, the carpets which are only in the living room and dining room have been there for the eight years Administrator has, and another staff steam cleans them approximately once a month. Investigation revealed the facility is not safe because there are swamp coolers/air conditioners blocking the glass door and the back door. The facility is not clean due to shared back south bedroom in disarray and not sanitary because of the bathroom shower & ceiling with what appears to be mold. Due to observations & interviews allegation Staff does not ensure facility is clean, safe, and sanitary is Substantiated.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of evidence standard has been met.



The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Although LPA observed temperature within the regulations swamp and other air conditioning system is obstructing exit doors which will be addressed on case management.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20240725130851
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MANZANITA HOUSE
FACILITY NUMBER: 176801307
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2024
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitor. This requirement is not met as evidenced by:
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Administrator agrees to clean/fix bathroom shower dirt/mold and in ceiling along with having back bedroom in order. Submit pictures of completion to LPA by POC due date 8/29/2024 to clear deficiency.
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Based on LPAs observations and interview with Administrator the facility did not ensure bathroom sanitary with shower & ceiling not free of dirt/mold, clients (southeast) room not clean.
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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: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20240725130851

FACILITY NAME:MANZANITA HOUSEFACILITY NUMBER:
176801307
ADMINISTRATOR:MARIAH UDENFACILITY TYPE:
735
ADDRESS:3997 MANZANITA DRIVETELEPHONE:
(707) 274-9293
CITY:NICESTATE: CAZIP CODE:
95464
CAPACITY:6CENSUS: DATE:
08/08/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff does not provide a comfortable temperature for residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived unannounced on this day for the purpose of delivering findings of the above allegation. LPA met with Mariah Uden, Administrator.

During the course of this investigation LPA conducted interviews, made observations, and obtained documents.

Staff does not provide a comfortable temperature for residents in care – Complainant alleges on 7/18/2024 at approximately 2:30 pm facility bedrooms were 83 degrees. On 8/1/2024 at 9:30am LPA conducted facility walk through and observed temperatures in facility bedrooms to be 72.6, 75., & 75.3 degrees F. LPA was informed by Administrator the Central Air conditioner has not worked for approximately 2 years and HVAC company informed would need to be replace so in the living room we have placed a swamp cooler and an air conditioner with 2 fans along with the ceiling fan going all of the time. Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20240725130851
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MANZANITA HOUSE
FACILITY NUMBER: 176801307
VISIT DATE: 08/08/2024
NARRATIVE
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Continued from LIC9099-A

There is also an air conditioner in the back hallway and a fan in the hallway, as well as a fan in each of the back bedrooms that continuously run during hot weather (see pics). Per Title 22 Regulation 80088(a)(1)(A) Furniture, Fixtures, Equipment, and Supplies (a)A comfortable temperature for clients shall be maintained at all areas. (1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). (A) In areas of extreme heat, the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. LPA’s observation, interviews and complaint provided temperature, the facility temp appears to be within regulation stated, therefore the allegation Staff does not provide a comfortable temperature for residents in care if found to be UNSUBSTANTIATED.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5